SEC Form 4
FORM 4 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
or Section 30(h) of the Investment Company Act of 1940
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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).
1. Name and Address of Reporting Person*
BALLOU ROGER H

(Last) (First) (Middle)
3075 LOYALTY CIRCLE

(Street)
COLUMBUS OH 43219

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
ALLIANCE DATA SYSTEMS CORP [ ADS ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director 10% Owner
Officer (give title below) Other (specify below)
3. Date of Earliest Transaction (Month/Day/Year)
05/24/2021
4. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security (Instr. 3) 2. Transaction Date (Month/Day/Year) 2A. Deemed Execution Date, if any (Month/Day/Year) 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
Common Stock 05/24/2021 J(1) 3,178 A $117.915 19,499(3) D
Common Stock 0(1)(2) I By Roger H. Ballou 2020 Grantor Retained Annuity Trust
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 (Month/Day/Year) 3A. Deemed Execution Date, if any (Month/Day/Year) 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 (Month/Day/Year) 7. Title and Amount of Securities Underlying Derivative Security (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: 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
Explanation of Responses:
1. On May 24, 2021, the Reporting Person withdrew 3,178 shares of ADS common stock from the Roger H. Ballou 2020 Grantor Retained Annuity Trust. In exchange for the shares, the Reporting Person contributed cash in the amount of $374,733.87 to the trust. The withdrawal of shares from the trust resulted in a decrease in the number of shares the Reporting Person beneficially owns indirectly through the trust and a corresponding increase in the number of shares the Reporting Person beneficially owns directly. The Reporting Person believes that his withdrawal of shares from the trust constitutes a change in form of beneficial ownership of the shares, exempted by Rule 16a-13 under the Securities Exchange Act of 1934.
2. On May 20, 2021, 322 shares of ADS common stock were distributed to the Reporting Person by the Roger H. Ballou 2020 Grantor Retained Annuity Trust.
3. The total amount of securities beneficially owned includes: (a) 8,888 unrestricted shares; (b) 1,915 unvested restricted stock units granted 6/30/11; (c) 1,374 unvested restricted stock units granted 6/29/12; (d) 679 unvested restricted stock units granted 7/1/13; (e) 489 unvested restricted stock units granted 7/1/14; (f) 418 unvested restricted stock units granted 6/29/15; (g) 602 unvested restricted stock units granted 6/27/16; (h) 564 unvested restricted stock units granted 6/26/17; (i) 655 unvested restricted stock units granted 6/25/18; (j) 959 unvested restricted stock units granted 6/24/19; and (k) 2,956 unvested restricted stock units granted 6/22/20.
Cynthia L. Hageman, Attorney in Fact 05/25/2021
** Signature of Reporting Person Date
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).
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
Note: 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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