Sec Form 4 Filing - Barrett Peter D @ SUPREME INDUSTRIES INC - 2017-09-06

Insider filing report for Changes in Beneficial Ownership
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FORM 4
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person
Barrett Peter D
2. Issuer Name and Ticker or Trading Symbol
SUPREME INDUSTRIES INC [ STS]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X __ Director _____ 10% Owner
_____ Officer (give title below) _____ Other (specify below)
(Last) (First) (Middle)
2581 EAST KERCHER ROAD
3. Date of Earliest Transaction (MM/DD/YY)
09/06/2017
(Street)
GOSHEN, IN46528
4. If Amendment, Date Original Filed (MM/DD/YY)
6. Individual or Joint/Group Filing (Check Applicable Line)
__ X __ Form filed by One Reporting Person
_____ Form filed by More than One Reporting Person
(City) (State) (Zip)
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1.Title of Security
(Instr. 3)
2. Transaction Date (MM/DD/YY) 2A. Deemed Execution Date, if any (MM/DD/YY) 3. Transaction Code
(Instr. 8)
4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
5. Amount of Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 3 and 4)
6. Ownership Form: Direct (D) or Indirect (I)
(Instr. 4)
7. Nature of Indirect Beneficial Ownership
(Instr. 4)
Code V Amount (A) or (D) Price
Class A Common Stock 09/06/2017 J( 1 ) 26,700 A $ 0 26,700 I By Trust ( 2 ) ( 3 ) ( 4 )
Class A Common Stock 09/06/2017 J 26,700 ( 5 ) D $ 0 0 I By Trust ( 2 ) ( 3 ) ( 4 )
Class A Common Stock 33,321 ( 6 ) D ( 3 ) ( 4 )
Class B Common Stock 29,467 ( 7 ) D ( 3 ) ( 4 )
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
( e.g. , puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security
(Instr. 3)
2. Conversion or Exercise Price of Derivative Security 3. Transaction Date (MM/DD/YY) 3A. Deemed Execution Date, if any (MM/DD/YY) 4. Transaction Code
(Instr. 8)
5. Number of Derivative Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4, and 5)
6. Date Exercisable and Expiration Date
(MM/DD/YY)
7. Title and Amount of Underlying Securities
(Instr. 3 and 4)
8. Price of Derivative Security
( Instr. 5)
9. Number of Derivative Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 4)
10. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
(Instr. 4)
11. Nature of Indirect Beneficial Ownership
(Instr. 4)
Code V (A) (D) Date Exercisable Expiration Date Title Amount or Number of Shares
Reporting Owners
Reporting Owner Name / Address Relationships
Director 10% Owner Officer Other
Barrett Peter D
2581 EAST KERCHER ROAD
GOSHEN, IN46528
X
Signatures
s/ Julia A. Gardner, Attorney-in-Fact for Peter D. Barrett 09/14/2017
Signature of Reporting Person Date
Explanation of Responses:
( 1 )Represents shares of Class A common stock of Supreme Industries, Inc., par value $0.10 per share ("Class A Shares"), that were ultimately received in connection with a distribution by an independently controlled limited liability company to its members.
( 2 )Represents Class A Shares held directly by the Peter D. Barrett 2012 Irrevocable Trust (the "Trust"). Peter D. Barrett is the trustee and beneficiary of, and may be deemed to beneficially own securities held by, the Trust.
( 3 )This statement is filed by and on behalf of Peter D. Barrett. Mr. Barrett and the Trust are the direct beneficial owners of the securities covered by this statement.
( 4 )The reporting person states that neither the filing of this statement nor anything herein shall be deemed an admission that such person is, for purposes of Section 16 of the Securities Exchange Act of 1934, as amended (the "Exchange Act"), or otherwise, the beneficial owner of any securities covered by this statement. The reporting person disclaims beneficial ownership of the securities covered by this statement, except to the extent of the pecuniary interest of such person in such securities.
( 5 )Represents Class A Shares that were distributed by the Trust to Mr. Barrett, as the sole beneficiary of the Trust (the "Trust Distribution").
( 6 )Includes all 26,700 Class A Shares that were distributed by the Trust to Mr. Barrett in connection with the Trust Distribution. The acquisition of such Class A Shares by Mr. Barrett in connection with the Trust Distribution constituted a change in the form of beneficial ownership without a change in pecuniary interest that is exempt from Section 16 of the Exchange Act pursuant to Rule 16a-13 thereunder. Rule 16a-9(a) under the Exchange Act may also exempt the acquisition of such Class A Shares by Mr. Barrett in connection with the Trust Distribution from Section 16 of the Exchange Act.
( 7 )Represents shares of Class B common stock of Supreme Industries, Inc., par value $0.10 per share ("Class B Shares"). Class B Shares are freely convertible on a one-to-one basis into an equal number of Class A Shares.

Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
* If the form is filed by more than one reporting person, see Instruction 4(b)(v).
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