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*
C/O KOHLBERG KRAVIS ROBERTS & CO. L.P. |
9 WEST 57TH STREET, SUITE 4200 |
(Street)
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2. Issuer Name and Ticker or Trading Symbol
Jazz Pharmaceuticals plc
[ JAZZ ]
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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) |
See Footnotes (1) - (7) |
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3. Date of Earliest Transaction
(Month/Day/Year) 01/18/2012
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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 |
01/18/2012 |
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U
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9,906,501 |
D |
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0 |
I |
Held by KKR JP LLC
See footnotes
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Common Stock |
01/18/2012 |
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U
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36,445 |
D |
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0 |
I |
Held by KKR JP III LLC
See footnotes
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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 |
Common Stock Warrant (right to buy) |
$7.37
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01/18/2012 |
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U
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597,837 |
01/21/2009 |
07/21/2014 |
Common Stock |
597,837 |
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0 |
I |
Held by KKR JP LLC
See footnotes
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1. Name and Address of Reporting Person*
C/O KOHLBERG KRAVIS ROBERTS & CO. L.P. |
9 WEST 57TH STREET, SUITE 4200 |
(Street)
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1. Name and Address of Reporting Person*
C/O KOHLBERG KRAVIS ROBERTS & CO. L.P. |
9 WEST 57TH STREET, SUITE 4200 |
(Street)
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1. Name and Address of Reporting Person*
C/O KOHLBERG KRAVIS ROBERTS & CO. L.P. |
9 WEST 57TH STREET, SUITE 4200 |
(Street)
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1. Name and Address of Reporting Person*
C/O KOHLBERG KRAVIS ROBERTS & CO. L.P. |
9 WEST 57TH STREET, SUITE 4200 |
(Street)
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1. Name and Address of Reporting Person*
C/O KOHLBERG KRAVIS ROBERTS & CO. L.P. |
9 WEST 57TH STREET, SUITE 4200 |
(Street)
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1. Name and Address of Reporting Person*
C/O KOHLBERG KRAVIS ROBERTS & CO. L.P. |
9 WEST 57TH STREET, SUITE 4200 |
(Street)
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1. Name and Address of Reporting Person*
C/O KOHLBERG KRAVIS ROBERTS & CO. L.P. |
9 WEST 57TH STREET, SUITE 4200 |
(Street)
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1. Name and Address of Reporting Person*
C/O KOHLBERG KRAVIS ROBERTS & CO. L.P. |
9 WEST 57TH STREET, SUITE 4200 |
(Street)
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1. Name and Address of Reporting Person*
C/O KOHLBERG KRAVIS ROBERTS & CO. L.P. |
9 WEST 57TH STREET, SUITE 4200 |
(Street)
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1. Name and Address of Reporting Person*
C/O KOHLBERG KRAVIS ROBERTS & CO. L.P. |
9 WEST 57TH STREET, SUITE 4200 |
(Street)
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Explanation of Responses: |
Remarks: |
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KKR JP LLC, /s/ Richard J. Kreider, Name: Richard J. Kreider, Title: Attorney-in-fact for William J. Janetschek, Chief Financial Officer |
01/18/2012 |
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KKR Millennium Fund L.P., By: KKR Associates Millennium L.P, Its: General Partner, By: KKR Millennium GP LLC, Its: General Partner, /s/ Richard J. Kreider, Title: Attorney-in-fact for Henry R. Kravis, Manager and George R. Roberts, Manager |
01/18/2012 |
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KKR Associates Millennium L.P., By: KKR Millennium GP LLC, Its: General Partner, /s/ Richard J. Kreider, Title: Attorney-in-fact for Henry R. Kravis, Manager and George R. Roberts, Manager |
01/18/2012 |
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KKR Millennium GP LLC, /s/ Richard J. Kreider,
Title: Attorney-in-fact for Henry R. Kravis, Manager and George R. Roberts, Manager |
01/18/2012 |
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KKR Fund Holdings L.P., By: KKR Fund Holdings GP Limited, Its: General Partner, /s/ Richard J. Kreider, Title: Attorney-in-fact for William J. Janetschek, Director |
01/18/2012 |
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KKR Fund Holdings GP Limited, /s/ Richard J. Kreider, Title: Attorney-in-fact for William J. Janetschek, Director |
01/18/2012 |
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KKR Group Holdings L.P., By: KKR Group Limited, Its: General Partner, /s/ Richard J. Kreider, Name: Richard J. Kreider, Title: Attorney-in-fact for William J. Janetschek, Director |
01/18/2012 |
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KKR Group Limited, /s/ Richard J. Kreider, Title: Attorney-in-fact for William J. Janetschek, Director |
01/18/2012 |
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KKR & Co. L.P., By: KKR Management LLC, Its: General Partner, /s/ Richard J. Kreider, Title: Attorney-in-fact for William J. Janetschek, Chief Financial Officer |
01/18/2012 |
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KKR Management LLC, /s/ Richard J. Kreider, Title: Attorney-in-fact for William J. Janetschek, Chief Financial Officer |
01/18/2012 |
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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. |
Power of Attorney
POWER OF ATTORNEY
Know all men by these
presents that William J. Janetschek does hereby make, constitute and appoint
Richard J. Kreider, as a true and lawful attorney-in-fact of the undersigned
with full powers of substitution and revocation, for and in the name, place and
stead of the undersigned (both in the undersigned’s individual capacity
and as a member of any limited liability company or as a partner of any
partnership for which the undersigned is otherwise authorized to sign), to
execute and deliver such forms as may be required to be filed from time to time
with the Securities and Exchange Commission with respect to:
(i) Sections 13(d) and 16(a) of the Securities Exchange Act of 1934,
as amended (the “Act”), including without limitation,
Schedule 13D, Schedule 13G, statements on Form 3, Form 4
and Form 5 and (ii) in connection with any applications for EDGAR
access codes, including without limitation the Form ID.
/s/ William J. Janetschek
Name: William J. Janetschek
Date: February 1, 2010