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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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*
Bisignano Frank

(Last) (First) (Middle)
255 FISERV DRIVE

(Street)
BROOKFIELD WI 53045

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
FISERV INC [ FISV ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director 10% Owner
X Officer (give title below) Other (specify below)
President and CEO
3. Date of Earliest Transaction (Month/Day/Year)
12/31/2020
4. 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 Acquired, Disposed of, or Beneficially Owned
1. Title of Security (Instr. 3) 2. Transaction Date (Month/Day/Year) 2A. Deemed Execution Date, if any (Month/Day/Year) 3. Transaction 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 Stock 08/28/2020 G V 4,345 D $0.00 2,367,627(1) D
Common Stock 09/21/2020 G V 9,742 D $0.00 2,357,885 D
Common Stock 11/12/2020 G V 3,484 D $0.00 2,354,401 D
Common Stock 11/13/2020 G V 226 D $0.00 2,354,175 D
Common Stock 11/23/2020 G V 42,373 D $0.00 2,311,802 D
Common Stock 11/30/2020 G V 1,744 D $0.00 2,310,058 D
Common Stock 12/16/2020 G V 86,700 D $0.00 2,223,358 D
Common Stock 12/29/2020 G V 266 D $0.00 2,223,092 D
Common Stock 12/30/2020 G V 1,509 D $0.00 2,221,583 D
Common Stock 12/31/2020 F 30,900(2) D $113.86 2,190,683 D
Common Stock 11/23/2020 G V 42,373 A $0.00 50,190 I By Spouse
Common Stock 12/16/2020 G V 34,500 D $0.00 15,690 I By Spouse
Common Stock 1,447(3) I See Footnote(4)
Common Stock 76,713 I By Trust(5)
Common Stock 75,000 I By Trust(6)
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 3) 2. Conversion or Exercise Price of Derivative Security 3. Transaction Date (Month/Day/Year) 3A. Deemed Execution Date, if any (Month/Day/Year) 4. Transaction 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 (Month/Day/Year) 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: 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
Explanation of Responses:
1. Includes 290 shares distributed to the reporting person on June 8, 2020 from a revocable trust for which the reporting person served as trustee (the "revocable trust") and 285 shares previously reported as a gift from direct ownership that was made from the revocable trust. Reflects the contribution of 75,000 shares to the Frank J. Bisignano 2020 Grantor Retained Annuity Trust on August 28, 2020.
2. Reflects payment of tax liability by withholding securities incident to vesting of restricted stock.
3. The reporting person no longer has a reportable beneficial interest in 1,561 shares of Fiserv common stock included in the reporting person's prior ownership reports.
4. These shares are held in an account for the benefit of the reporting person's child and of which the reporting person acts as custodian.
5. These shares are held by trusts for the benefit of the reporting person's children and of which the reporting person serves as trustee.
6. Held by the Frank J. Bisignano 2020 Grantor Retained Annuity Trust.
Remarks:
/s/ Lynn S. McCreary (attorney-in-fact) 01/04/2021
** 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.