- Statement of Changes in Beneficial Ownership (4)
23 Abril 2012 - 7:33PM
Edgar (US Regulatory)
FORM 4
[
X
]
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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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0287
Estimated average burden
hours per response...
0.5
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Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public
Utility Holding Company Act of 1935 or Section 30(f) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person
*
O'Shaughnessy J Patrick
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2. Issuer Name
and
Ticker or Trading Symbol
Advance America, Cash Advance Centers, Inc.
[
AEA
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__
X
__ Director
_____ 10% Owner
__
X
__ Officer (give title below)
_____ Other (specify below)
President & CEO
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(Last)
(First)
(Middle)
135 NORTH CHURCH STREET
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3. Date of Earliest Transaction
(MM/DD/YYYY)
4/23/2012
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(Street)
SPARTANBURG, SC 29306
(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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Code
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V
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Amount
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(A) or (D)
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Price
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Common Stock
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3/26/2012
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G
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V
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43500
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D
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$0
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784145
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D
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Common Stock
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4/23/2012
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D
(1)
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784145
(2)
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D
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$10.50
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0
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D
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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. 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
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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 Following Reported Transaction(s) (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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Code
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V
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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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$8.54
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4/23/2012
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D
(3)
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37500
(4)
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4/23/2012
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2/13/2018
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Common Stock
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37500
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$1.96
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0
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D
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Employee Stock Option (Right to Buy)
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$1.14
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4/23/2012
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D
(3)
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90000
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2/19/2011
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2/19/2019
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Common Stock
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90000
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$9.36
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0
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D
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Explanation of Responses:
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(
1)
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Disposed of pursuant to the Agreement and Plan of Merger (the "Agreement"), dated February 15, 2012, by and among the issuer, Eagle U.S. Sub, Inc., and Eagle U.S. Merger Sub, Inc. On the effective date of the merger contemplated by the Agreement, each share of common stock of the issuer was automatically converted into the right to receive $10.50.
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(
2)
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The shares reported on this line include 202,801 unvested shares of restricted stock that, pursuant to the Agreement, became fully vested immediately prior to the effective time of the merger and 250,000 shares of unvested restricted stock that were cancelled in exchange for cash payments of $10.50 per share, half of which were deferred in accordance with the Modification to the Change of Control Agreement dated February 15, 2012 between the reporting person and the issuer.
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(
3)
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Disposed of pursuant to the Agreement under which each of the reporting person's then outstanding in the money options to purchase shares of the issuer's common stock, whether or not vested or exercisable, became fully vested and exercisable and wereconverted into the right to receive an amount of cash equal to the product of (i) the excess of the merger consideration of $10.50 per share over the applicable exercise price per share and (ii) the number of shares of common stock subject to such option, without interest and less any applicable withholding taxes.
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(
4)
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The shares reported on this line include 7,500 shares that, pursuant to the Agreement, became fully vested and exercisable immediately prior to the effective time of the merger.
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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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O'Shaughnessy J Patrick
135 NORTH CHURCH STREET
SPARTANBURG, SC 29306
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X
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President & CEO
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Signatures
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/s/ Merrick D. Hatcher, Attorney-in-fact
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4/23/2012
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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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