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FORM 4
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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).
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
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OMB APPROVAL
OMB Number: 3235-0287 Estimated average burden hours per response... 0.5 |
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1. Name and Address of Reporting Person
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Schwartz Daniel S |
2. Issuer Name
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Ticker or Trading Symbol
Restaurant Brands International Inc. [ QSR ] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__ X __ Director _____ 10% Owner __ X __ Officer (give title below) _____ Other (specify below) Chief Executive Officer |
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226 WYECROFT ROAD |
3. Date of Earliest Transaction
(MM/DD/YYYY)
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OAKVILLE, A6 L6K 3X7 |
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) |
2. Trans. Date | 2A. Deemed Execution Date, if any |
3. Trans. 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 Shares | 37852 | 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) |
2. Conversion or Exercise Price of Derivative Security | 3. Trans. Date | 3A. Deemed Execution Date, if any |
4. Trans. 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 |
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 of Derivative Security: 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 | ||||||||
| Exchangeable units (1) (2) | (1) (2) | (2) | (2) | Common Shares | 137996 | 137996 | D | ||||||||
| Option (right to buy) | $3.54 | (3) | 2/2/2021 | Common Shares | 848420 | 848420 | D | ||||||||
| Option (right to buy) | $3.54 | (3) | 2/20/2022 | Common Shares | 211658 | 211658 | D | ||||||||
| Option (right to buy) | $3.97 | (3) | 2/28/2022 | Common Shares | 503074 | 503074 | D | ||||||||
| Option (right to buy) | $18.25 | 12/31/2017 | 2/28/2023 | Common Shares | 46575 | 46575 | D | ||||||||
| Option (right to buy) | $18.25 | 3/1/2018 | 2/28/2023 | Common Shares | 500000 | 500000 | D | ||||||||
| Option (right to buy) | $27.28 | 12/31/2018 | 3/6/2024 | Common Shares | 95307 | 95307 | D | ||||||||
| Option (right to buy) | $27.28 | 3/7/2019 | 3/6/2024 | Common Shares | 400000 | 400000 | D | ||||||||
| Option (right to buy) | $42.26 | 12/31/2019 | 3/5/2025 | Common Shares | 82820 | 82820 | D | ||||||||
| Option (right to buy) | $42.26 | 3/6/2020 | 3/5/2025 | Common Shares | 333333 | 333333 | D | ||||||||
| Restricted Share Units | (4) | (5) | (5) | Common Shares | 57915 | 57915 | D | ||||||||
| Dividend Equivalent Rights | (6) | 10/3/2017 | A | 183.9919 | (7) | (7) | Common Shares | 183.9919 | $0.00 | 1394.7948 | D | ||||
| Option (right to buy) | $33.67 | 2/26/2021 | 2/25/2026 | Common Shares | 250000 | 250000 | D | ||||||||
| Restricted Share Units | (4) | (8) | (8) | Common Shares | 26850 | 26850 | D | ||||||||
| Dividend Equivalent Rights | (6) | 10/3/2017 | A | 84.0797 | (9) | (9) | Common Shares | 84.0797 | $0.00 | 253.0918 | D | ||||
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Reporting Owners
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| Reporting Owner Name / Address |
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| Director | 10% Owner | Officer | Other | ||
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Schwartz Daniel S
226 WYECROFT ROAD OAKVILLE, A6 L6K 3X7 |
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Chief Executive Officer |
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Signatures
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| /s/ Lisa Giles-Klein, As Attorney-in-Fact for Daniel S. Schwartz | 10/5/2017 | |
| ** Signature of Reporting Person |
Date
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| 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. |
| 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. | |