Annual Statement of Changes in Beneficial Ownership (5)
12 Dezember 2012 - 8:57PM
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
*
SHAW STEVEN A
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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
__
X
__ 10% Owner
_____ Officer (give title below)
_____ Other (specify below)
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(Last)
(First)
(Middle)
346 CLAYPOOL DRIVE
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3. Statement for Issuer's Fiscal Year Ended
(MM/DD/YYYY)
10/28/2012
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(Street)
WARWICK, RI 02886
(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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3/5/2012
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G
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100000
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A
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$0
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1340230
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D
(1)
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Common Stock, $0.10 par value
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147250
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I
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As Co-Trustee
(2)
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Common Stock, $0.10 par value
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331649
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I
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As Co-Trustee
(3)
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Common Stock, $0.10 par value
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180662
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I
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As Co-Trustee
(4)
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Common Stock, $0.10 par value
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3/5/2012
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G
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100000
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A
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$0
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461325
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I
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As Co-Trustee
(5)
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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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Employee Stock Option (Right to Buy)
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$7.1133
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(6)
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3/10/2013
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Common Stock, $.10 par value
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6000
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6000
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D
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Employee Stock Option (Right to Buy)
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$13.32
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(7)
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12/17/2017
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Common Stock, $.10 par value
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20000
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20000
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D
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Restricted Stock Units
(8)
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(9)
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12/17/2017
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Common Stock, $.10 par value
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20000
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20000
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D
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Employee Stock Option (Right to Buy)
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$6.39
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(10)
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4/6/2019
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Common Stock, $.10 par value
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8000
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8000
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D
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Explanation of Responses:
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(
1)
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Since the date of the last report, the 131 shares previously held in the reporting person's Employee Stock Ownership Plan account in the Company Savings Plan and 16,306 shares held in the reporting person's Stock Fund under the reporting person's 401(k) Plan account in the Company Savings Plan were rolled over into a self-directed IRA and therefore are now owned directly.
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(
2)
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Held as co-trustee, with the reporting person's brother and a director of the issuer, of a trust of which the reporting person is the beneficiary.
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(
3)
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Held as co-trustee, with the reporting person's brother and a director of the issuer, of trusts of which the reporting person's brother and sister, respectively, are beneficiaries.
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(
4)
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Held as co-trustee, with the reporting person's brother, sister and a director of the issuer, of a trust of which the reporting person is the beneficiary.
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(
5)
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Held as co-trustee, with the reporting person's brother, sister and a director of the issuer, of trusts of which the reporting person's brother and sister, respectively, are beneficiaries.
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(
6)
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Currently exercisable in full.
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(
7)
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Options may have been "earned" subject to the Company's achievement of certain performance goals measured at the end of the Company's 2012 fiscal year, ended October 28, 2012. There has been no determination as to whether or not any such options have been earned, and if so, the number of options earned. Such options, to the extent "earned," are scheduled, subject to certain conditions, to vest in four equal annual installments on the 15th day of the third month of each of the Company's 2013, 2014, 2015 and 2016 fiscal years. The end of the Company's fiscal year is the Sunday nearest October 31, 2012.
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(
8)
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Each restricted stock unit represents the right to one share of common stock.
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(
9)
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Each share of common stock represented by a restricted stock unit may be "earned" subject to the Company's achievement of certain performance goals measured at the end of the Company's 2011 fiscal year, ended October 30, 2011. There has been no determination as to whether or not any such shares have been earned, and if so, the number of shares earned. Such shares, to the extent "earned," are scheduled, subject to certain conditions, to vest in five equal annual installments on the 15th day of the third month of each of the Company's 2012, 2013, 2014, 2015 and 2016 fiscal years. The end of the Company's fiscal year is the Sunday nearest to October 31.
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(
10)
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The 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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SHAW STEVEN A
346 CLAYPOOL DRIVE
WARWICK, RI 02886
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X
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X
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Signatures
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/s/ Steven A. Shaw
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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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