SEC FORM 3 SEC Form 3
FORM 3 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES

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*
SILVERMAN HARRY

(Last) (First) (Middle)
C/O DOMINO'S PIZZA, INC.
30 FRANK LLOYD WRIGHT DRIVE

(Street)
ANN ARBOR MI 48106

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
07/13/2004
3. Issuer Name and Ticker or Trading Symbol
DOMINOS PIZZA INC [ DPZ ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director 10% Owner
X Officer (give title below) Other (specify below)
Chief Financial Officer
5. 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 Beneficially Owned
1. Title of Security (Instr. 4) 2. Amount of Securities Beneficially Owned (Instr. 4) 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 4. Nature of Indirect Beneficial Ownership (Instr. 5)
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 4) 2. Date Exercisable and Expiration Date (Month/Day/Year) 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) 4. Conversion or Exercise Price of Derivative Security 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 6. Nature of Indirect Beneficial Ownership (Instr. 5)
Date Exercisable Expiration Date Title Amount or Number of Shares
Option to Purchase Common Stock 06/25/2003 01/24/2010 Common Stock, $.01 par value 334,916 0.75 D
Option to Purchase Common Stock 06/25/2003 01/01/2012 Common Stock, $.01 par value 33,333 5.25 D
Option to Purchase Common Stock 07/01/2008(1) 07/01/2013 Common Stock, $.01 par value 166,666 8.66 D
Option to Purchase Common Stock 07/13/2009(2) 07/13/2014 Common Stock, $.01 par value 133,333 14 D
Explanation of Responses:
1. The Options to Purchase Common Stock vest 20% each year on the anniversary of the Option to Purchase grant date. Thus 20% vested on July 1, 2004 and an additional 20% will vest on each of July 1, 2005, July 1, 2006, July 1, 2007 and July 1, 2008.
2. The Options to Purchase Common Stock vest 20% each year for five years. Thus 20% will vest on each of July 3, 2005, July 13, 2006, July 13, 2007, July 13, 2008 and July 13, 2009.
/s/ Harry J. Silverman 07/13/2004
** 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 5 (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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