Annual Statement of Changes in Beneficial Ownership (5)
12 Dezember 2012 - 8:47PM
Edgar (US Regulatory)
FORM 5
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b).
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Form 3 Holdings Reported
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Form 4 Transactions Reported
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0362
Estimated average burden
hours per response...
1.0
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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
*
GOODMAN BRUCE G
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2. Issuer Name
and
Ticker or Trading Symbol
VOLT INFORMATION SCIENCES, INC. [VISI]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__
X
__ Director
_____ 10% Owner
_____ Officer (give title below)
_____ Other (specify below)
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(Last)
(First)
(Middle)
SHEPHERD KAPLAN LLC, 125 SUMMER STREET
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3. Statement for Issuer's Fiscal Year Ended
(MM/DD/YYYY)
10/28/2012
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(Street)
BOSTON, MA 02110
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
_
X
_ Form Filed by One Reporting Person
___ Form Filed by More than One Reporting Person
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security
(Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code
(Instr. 8)
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4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I)
(Instr. 4)
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7. Nature of Indirect Beneficial Ownership
(Instr. 4)
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Amount
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(A) or (D)
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Price
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Common Stock, $0.10 par value
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19244
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D
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Common Stock, $0.10 par value
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1500
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I
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As Trustee
(1)
(2)
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Common Stock, $0.10 par value
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5/22/2012
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G
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206063
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A
(3)
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$0
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436205
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I
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As Co-Trustee
(1)
(4)
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Common Stock, $0.10 par value
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9/12/2012
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G
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8000
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A
(5)
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$0
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56956
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I
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A Co-Trustee
(1)
(6)
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Common Stock, $0.10 par value
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5/22/2012
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G
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206063
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D
(3)
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$0
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507426
(7)
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I
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By Spouse
(1)
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Common Stock, $0.10 par value
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9/12/2012
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G
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8000
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D
(5)
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$0
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507426
(7)
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I
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By Spouse
(1)
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Common Stock, $0.10 par value
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941813
(7)
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I
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By Spouse's GRATs
(1)
(8)
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Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (
e.g.
, puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 3)
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2. Conversion or Exercise Price of Derivative Security
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3. Trans. Date
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3A. Deemed Execution Date, if any
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4. Trans. Code
(Instr. 8)
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5. Number of Derivative Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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6. Date Exercisable and Expiration Date
(MM/DD/YYYY)
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7. Title and Amount of Securities Underlying Derivative Security
(Instr. 3 and 4)
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8. Price of Derivative Security
(Instr. 5)
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9. Number of Derivative Securities Beneficially Owned at End of Issuer's Fiscal Year
(Instr. 4)
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10. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
(Instr. 4)
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11. Nature of Indirect Beneficial Ownership
(Instr. 4)
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(A)
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(D)
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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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Stock Option (Right to Buy)
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$6.39
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(9)
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4/6/2019
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Common Stock, $.10 par value
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3000
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3000
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D
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Explanation of Responses:
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(
1)
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The filing of this statement shall not be construed as an admission that the reporting person is, for purposes of Section 16 of the Securities Exchange Act of 1934 or otherwise, the beneficial owner of these securities.
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(
2)
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Held by the reporting person as trustee of an irrevocable trust for the benefit of a child of reporting person.
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(
3)
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Distributed to the reporting person and the sister (who is a director of the issuer) of the spouse of the reporting person, as co-trustees of a trust for the benefit of children of the reporting person upon gift from the spouse of the reporting person.
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(
4)
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Held by the reporting person and the sister (who is a director of the issuer) of the spouse of the reporting person, as co-trustees of a trust for the benefit of children of the reporting person.
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(
5)
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Distributed to the reporting person, the spouse of the reporting person and the sister (who is a director of the issuer) of the spouse of reporting person, as co-trustees of trusts for the benefit of children of the reporting person upon gift from the reporting person.
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(
6)
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Held by the reporting person, the spouse of the reporting person and the sister (who is a director of the issuer) of the spouse of reporting person, as co-trustees of trusts for the benefit of children of the reporting person.
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(
7)
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Column 5 of Table 1 gives effect to all transactions, including contributions to, and all annuity distributions from, Grantor Retained Annuity Trusts ("GRATs") created by the reporting person's spouse through the end of the Issuer's fiscal year rather than at the transaction date set forth in Column 2. Amounts in Column 5 reflect holdings at the end of the Issuer's fiscal year rather than at the transaction date set forth in Column 2. Certain of the transactions may not be reportable and, therefore, amounts shown in Column 5 may not foot to the amount previously reported as owned.
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(
8)
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Held by GRATs created by, and the sole trustee and sole annuitant of which is, the reporting person's spouse. Contributions to the GRATs by, and annuity distributions to, the reporting person's spouse are exempt from reporting pursuant to Rule 16a-13.
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(
9)
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This option is exercisable in 20% annual installments, on a cumulative basis, commencing April 7, 2010, one year after the date of grant of the option.
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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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GOODMAN BRUCE G
SHEPHERD KAPLAN LLC
125 SUMMER STREET
BOSTON, MA 02110
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X
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Signatures
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/s/ Bruce G. Goodman
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12/12/2012
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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 4(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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