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*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
11/27/2017
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3. Issuer Name and Ticker or Trading Symbol
DESTINATION XL GROUP, INC.
[ DXLG ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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Director |
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10% Owner |
| X |
Officer (give title below) |
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Other (specify below) |
| SVP, Store Sales & Operations |
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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 |
|---|
| 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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| Common Stock, $0.01 par value |
29,352 |
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 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 |
| Non-Qualified Stock Option (Right to Buy) |
01/31/2015 |
05/28/2023 |
Common Stock |
18,719 |
5.04 |
D |
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| Restricted Stock Unit |
04/01/2018 |
04/14/2026 |
Common Stock |
4,844
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0
|
D |
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| Restricted Stock Unit |
04/01/2019 |
04/03/2027 |
Common Stock |
9,649
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0
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D |
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| Explanation of Responses: |
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| Remarks: |
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Robert S. Molloy, Attorney-in-Fact for Anthony Gaeta |
11/30/2017 |
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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
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. |
EXHIBIT 24
CONFIRMING STATEMENT
This Statement confirms that the undersigned, Anthony Gaeta
has authorized and designated David A. Levin and Robert S. Molloy
to execute and file on the undersigned's behalf all Forms 3, 4 and 5
(including any amendments thereto) that the undersigned may be required
to file with the United States Securities and Exchange Commission as a
result of the undersigned's ownership of or transactions in securities of
Destination XL Group, Inc. The authority of David A. Levin and
Robert S. Molloy under this Statement shall continue until the
undersigned is no longer required to file Forms 3, 4 and 5 with regard to
the undersigned's ownership of or transactions in the securities of
Destination XL Group, Inc., unless earlier revoked in writing. The
undersigned acknowledges that David A. Levin and Robert S. Molloy are
not assuming any of the undersigned's responsibilities to comply with
Section 16 of the Securities Exchange Act of 1934.
Date: November 27, 2017 By: /s/ Anthony Gaeta
Name: ANTHONY GAETA
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