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Amo Mojica Jose del

Filed: 3 Feb 22, 7:17pm
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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X
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*
del Amo Mojica Jose

(Last) (First) (Middle)
1441 F.D. ROOSEVELT AVE., 6TH FLOOR

(Street)
SAN JUAN PR 00936

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
TRIPLE-S MANAGEMENT CORP [ GTS ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director 10% Owner
X Officer (give title below) Other (specify below)
President, TSP and TIA
3. Date of Earliest Transaction (Month/Day/Year)
02/01/2022
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 02/01/2022 A 36,355(1) A $0.00 88,480 D
Common Stock 02/01/2022 D 88,480(2) D $36(3) 0 D
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. Shares represent common stock earned pursuant to the grant of Performance Shares. Pursuant to the Merger Agreement between Triple-S Management Corporation (the "Issuer"), GuideWell Mutual Holding Corporation and GuideWell Merger, Inc. dated August 23, 2021 (the "Merger Agreement"), such Performance Shares were granted based on a performance metric agreed to by the parties in the Merger Agreement. The Performance Shares resulting in the right to receive such shares of Common Stock do not constitute derivative securities. As a result, such Performance Shares were nor required to be reported and were not reported on a Form 4 at the time of the award.
2. The amount of securities beneficially owned reported in Column 4 includes certain restricted stock that was accelerated and vested in accordance with the the terms of the Merger Agreement.
3. Pursuant to the terms of the Merger Agreement, all issued and outstanding shares of the Issuer were acquired at $36 per share.
Remarks:
/s/ Manuel Rodriguez-Boissen, Attorney-in-Fact 02/03/2022
** 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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