SEC FORM
4
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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OMB APPROVAL |
OMB Number: |
3235-0287 |
Estimated average burden |
hours per response: |
0.5 |
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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*
3500 DOUGLAS BLVD., SUITE 160 |
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(Street)
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2. Issuer Name and Ticker or Trading Symbol
MOLINA HEALTHCARE INC
[ MOH ]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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Director |
X |
10% Owner |
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Officer (give title below) |
X |
Other (specify below) |
Trustee and executor |
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3. Date of Earliest Transaction
(Month/Day/Year) 12/14/2017
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4. If Amendment, Date of Original Filed
(Month/Day/Year)
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6. Individual or Joint/Group Filing (Check Applicable Line)
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Form filed by One Reporting Person |
X |
Form filed by More than One Reporting Person |
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned |
1. Title of Security (Instr.
3)
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2. Transaction Date
(Month/Day/Year) |
2A. Deemed Execution Date, if any
(Month/Day/Year) |
3. Transaction 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 |
V |
Amount |
(A) or (D) |
Price |
Common Stock |
12/14/2017 |
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S
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22,500 |
D |
$74.5062
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3,174,292 |
I |
Trustee
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Common Stock |
12/15/2017 |
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S
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22,500 |
D |
$76.1276
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3,151,792 |
I |
Trustee
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Common Stock |
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28,258 |
I |
Trustee
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Common Stock |
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254,209 |
I |
Trustee
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Common Stock |
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47,273 |
I |
Executor
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Common Stock |
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208,795 |
I |
Trustee
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Common Stock |
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239,381 |
I |
Trustee
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Common Stock |
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295,750 |
I |
Trustee
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Common Stock |
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344,906 |
I |
Trustee
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Common Stock |
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172,990 |
I |
Trustee
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Common Stock |
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192,705 |
I |
Trustee
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Common Stock |
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206,719 |
I |
Trustee
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Common Stock |
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300 |
I |
Trustee
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Common Stock |
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1,496 |
I |
Trustee
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Common Stock |
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154,291 |
I |
Trustee
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Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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1. Title of Derivative Security (Instr.
3)
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2. Conversion or Exercise Price of Derivative Security
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3. Transaction Date
(Month/Day/Year) |
3A. Deemed Execution Date, if any
(Month/Day/Year) |
4. Transaction 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
(Month/Day/Year) |
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: Direct (D) or Indirect (I) (Instr.
4)
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11. Nature of Indirect Beneficial Ownership (Instr.
4)
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Code |
V |
(A) |
(D) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
1. Name and Address of Reporting Person*
3500 DOUGLAS BLVD., SUITE 160 |
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(Street)
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1. Name and Address of Reporting Person*
(Street)
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Explanation of Responses: |
Remarks: |
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/s/ William Dentino, by Karen Calhoun, Attorney-In-Fact |
12/18/2017 |
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/s/ Curtis Pedersen, by Karen Calhoun, Attorney-In-Fact |
12/18/2017 |
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** 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. |
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 Number. |
EXHIBIT 99
To William Dentino Form 4
ADDITIONAL REPORTING PERSONS
Owners:
Estate of Mary R. Molina
c/o 3500 Douglas Blvd., Suite 160, Roseville, CA 95661
/s/ William Dentino, Sole Executor, by Karen Calhoun, Attorney-In-Fact
Mary R. Molina Living Trust
Exempt Mary R. Molina Living Trust
Mary R. Molina Grantor Retained Annuity Trust 609/4
Mary R. Molina Grantor Retained Annuity Trust 609/7
Mary R. Molina Grantor Retained Annuity Trust 1209/3
Mary R. Molina Grantor Retained Annuity Trust 1209/4
Mary R. Molina Grantor Retained Annuity Trust 610/4
Mary R. Molina Grantor Retained Annuity Trust 610/5
Mary R. Molina Grantor Retained Annuity Trust 1210/4
Mary R. Molina Grantor Retained Annuity Trust 811/3
Mary R. Molina Grantor Retained Annuity Trust 812/3
c/o 3500 Douglas Blvd., Suite 160, Roseville, CA 95661
/s/ William Dentino and Curtis Pedersen, Co-Trustees, by Karen Calhoun,
Attorney-In-Fact
Dentino Family Trust
c/o 3500 Douglas Blvd., Suite 160, Roseville, CA 95661
/s/ William Dentino, Sole Trustee, by Karen Calhoun, Attorney-In-Fact
Curtis and Rosi Pedersen 2012 Trust
6218 East 6th Street, Long Beach, CA 90803
/s/ Curtis Pedersen and Rosi Pedersen, Co-Trustees, by Karen Calhoun,
Attorney-In-Fact