Initial Statement of Beneficial Ownership (3)
July 30 2019 - 5:06PM
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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MILLER HEIDI
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2. Date of Event Requiring Statement (MM/DD/YYYY)
7/29/2019
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3. Issuer Name
and
Ticker or Trading Symbol
FISERV INC [FISV]
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(Last)
(First)
(Middle)
255 FISERV DRIVE
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4. 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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(Street)
BROOKFIELD, WI 53045
(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)
_
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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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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Explanation of Responses:
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Remarks:
On July 29, 2019, the merger (the "Merger") of 300 Holdings, Inc., a wholly owned subsidiary of Fiserv, Inc. (the "Issuer"), with and into First Data Corporation ("First Data"), pursuant to the Agreement and Plan of Merger, dated as of January 16, 2019, was completed. Prior to the completion of the Merger, no securities of the Issuer were beneficially owned by the Reporting Person. This report does not include the securities of the Issuer acquired by the Reporting Person upon the completion of the Merger. The Reporting Person will separately file a Form 4 reflecting the Reporting Person's acquisition of securities of the Issuer in connection with the completion of the Merger.
Exhibit List: Exhibit 24 - Power of Attorney
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No securities are beneficially owned.
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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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MILLER HEIDI
255 FISERV DRIVE
BROOKFIELD, WI 53045
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X
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Signatures
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/s/ Lynn S. McCreary (attorney-in-fact)
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7/30/2019
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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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