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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| OMB APPROVAL |
| OMB Number: |
3235-0104 |
| Estimated average burden |
| hours per response: |
0.5 |
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1. Name and Address of Reporting Person*
| 1301 AVENUE OF THE AMERICAS |
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(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
01/17/2018
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3. Issuer Name and Ticker or Trading Symbol
UNIVERSAL HEALTH SERVICES INC
[ UHS ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
| X |
Director |
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10% Owner |
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Officer (give title below) |
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Other (specify below) |
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5. If Amendment, Date of Original Filed
(Month/Day/Year)
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6. Individual or Joint/Group Filing (Check Applicable Line)
| X |
Form filed by One Reporting Person |
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Form filed by More than One Reporting Person |
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| Table I - Non-Derivative Securities Beneficially Owned |
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| 1. Title of Security (Instr.
4)
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2.
Amount of Securities Beneficially Owned (Instr.
4)
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3. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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4. Nature of Indirect Beneficial Ownership (Instr.
5)
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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 Derivative Security (Instr.
4)
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2. Date Exercisable and Expiration Date
(Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr.
4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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6. Nature of Indirect Beneficial Ownership (Instr.
5)
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| Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
| Explanation of Responses: |
| No securities are beneficially owned. |
|
/s/ Steve Filton, attorney-in-fact for Mr. Nimetz |
01/19/2018 |
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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
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. |
| 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
I, Warren J. Nimetz, do hereby designate Alan B. Miller, Steve Filton
and Charles F. Boyle to act as my lawful attorneys-in-fact to execute and
have delivered on my behalf, with the Securities and Exchange Commission
and the New York Stock Exchange, certain forms as they pertain to my
reporting of holdings of Universal Health Services, Inc., Common Stock.
Such necessary forms shall consis of a Form 3, Initial Statement of Beneficial
Ownership, Form 4, Statement of Changes in Beneficial Ownership and Form 5,
Annual Statement of Changes in Beneficial Ownership.
I hereby ratify and confirm all that said attorney shall lawfully do or
cause to be done by virtue hereof.
/s/ Warren J. Nimetz
Signed and dated on this 17th day of January, 2018.
The undersigned, Alan B. Miller, Steve Filton and Charles F. Boyle
hereby affirm that we are the persons named herein as attorneys-in-fact
and that our original signatures are affixed hereto.
/s/ Alan B. Miller
/s/ Steve Filton
/s/ Charles F. Boyle
Signed and dated on this 17th day of January, 2018.
COMMONWEALTH OF PENNSYLVANIA COUNTY OF MONTGOMERY
On this 17th day of January, in the year 2018, before me, Karen D. Sterner,
personally appeared Warren J. Nimetz, Alan B. Miller, Steve Filton and
Charles F. Boyle, personally known to me and have executed this
document in my presence.
/s/ Karen D. Sterner
(SEAL) Signature of Notary Public
COMMONWEALTH OF PENNSYLVANIA
NOTARIAL SEAL
Karen D. Sterner, Notary Public North Coventry Twp.,
Chester County My Commission Expires Aug. 31, 2021
MEMBER. PENNSYLVANIA ASSOCIATION OF NOTARIES
