Initial Statement of Beneficial Ownership (3)
10 Julio 2019 - 5:45PM
Edgar (US Regulatory)
FORM 3
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0104
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Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person
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Johnson John Paul
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2. Date of Event Requiring Statement (MM/DD/YYYY)
7/1/2019
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3. Issuer Name
and
Ticker or Trading Symbol
Evolent Health, Inc. [EVH]
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(Last)
(First)
(Middle)
C/O EVOLENT HEALTH, INC., 800 NORTH GLEBE ROAD, SUITE 500
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4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director
_____ 10% Owner
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X
___ Officer (give title below)
_____ Other (specify below)
Chief Financial Officer /
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(Street)
ARLINGTON, VA 22203
(City)
(State)
(Zip)
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5. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
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X
_ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person
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Table I - Non-Derivative Securities Beneficially Owned
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1.Title of Security
(Instr. 4)
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2. Amount of Securities Beneficially Owned
(Instr. 4)
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3. Ownership Form: Direct (D) or Indirect (I)
(Instr. 5)
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4. Nature of Indirect Beneficial Ownership
(Instr. 5)
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Class A Common Stock
(1)
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16921
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D
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Table II - Derivative Securities Beneficially Owned (
e.g.
, puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 4)
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2. Date Exercisable and Expiration Date
(MM/DD/YYYY)
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3. Title and Amount of Securities Underlying Derivative Security
(Instr. 4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
(Instr. 5)
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6. Nature of Indirect Beneficial Ownership
(Instr. 5)
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Date Exercisable
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Expiration Date
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Title
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Amount or Number of Shares
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Class A Common Stock Option (right to buy)
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(2)
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5/1/2026
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Class A Common Stock
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7896
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$12.22
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D
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Class A Common Stock Option (right to buy)
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(3)
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2/1/2027
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Class A Common Stock
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4595
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$18.25
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D
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Class A Common Stock Option (right to buy)
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(4)
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2/1/2028
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Class A Common Stock
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21044
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$13.95
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D
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Leveraged Restricted Stock Unit
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(5)
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(6)
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Class A Common Stock
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46687
(7)
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$0
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D
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Explanation of Responses:
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(1)
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Includes restricted stock units granted to Mr. Johnson pursuant to the Evolent Health, Inc. Omnibus Incentive Compensation Plan.
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(2)
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15,794 options were granted on May 1, 2016 and vest and become exercisable ratably in four annual installments beginning on May 1, 2017. Prior to the date of the event requiring the filing of this Form 3, 3,948 of these options that remain outstanding had vested.
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(3)
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6,127 options were granted on February 1, 2017 and vest and become exercisable ratably in four annual installments beginning on February 1, 2018. Prior to the date of the event requiring the filing of this Form 3, 1,532 of these options that remain outstanding had vested.
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(4)
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21,044 options were granted on February 1, 2018 and vest and become exercisable ratably in four annual installments beginning on February 1, 2019. Prior to the date of the event requiring the filing of this Form 3, 5,261 of these options that remain outstanding had vested.
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(5)
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The leveraged stock units ("LSUs") vest on March 1, 2022.
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(6)
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The LSUs do not expire.
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(7)
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Each LSU represents the contingent right to receive, upon vesting, between 0% and 200% of one share of the Issuer's Class A Common Stock, subject to the level of achievement of applicable performance conditions. The resulting number of shares acquired upon vesting of the LSUs if any is based on the cumulative performance of the Issuer's Class A Common Stock.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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Johnson John Paul
C/O EVOLENT HEALTH, INC.
800 NORTH GLEBE ROAD, SUITE 500
ARLINGTON, VA 22203
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Chief Financial Officer
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Signatures
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/s/ Jonathan Weinberg, Attorney-in-fact
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7/10/2019
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 5(b)(v).
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**
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Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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Note:
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File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure.
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Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB control number.
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