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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | 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 control number. | SEC 2270 (9-02) |
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 Underlying Securities (Instr. 3 and 4) |
8. Price of Derivative Security (Instr. 5) |
9. Number of Derivative Securities Beneficially Owned at End of Issuer's Fiscal Year (Instr. 4) |
10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
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(A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
TAMBAKERAS MARKOS I 1 INTERNATIONAL DRIVE C/O XYLEM INC. RYE BROOK, NY 10573 |
 X |  |  |  |
/s/ Juliene Patton, by power of attorney for Markos I. Tambakeras | 02/15/2019 | |
**Signature of Reporting Person | Date |
* | 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). |
(1) | On August 8, 2018, 6,599 shares of Xylem Inc. common stock were transferred from the reporting person's family trust to the reporting person's 2018 Grantor Retained Annuity Trust account. |
(2) | An additional 20 shares accrued through a qualified DRIP. |
(3) | On December 21, 2018, 4,065 shares of Xylem Inc. common stock were gifted from the reporting person's personal brokerage account to the Tambakeras Family Trust, of which the reporting person is the sole beneficiary. |
(4) | Reflects a transfer of 31,005 shares of Xylem Inc. common stock from the reporting person's personal brokerage account to the Tambakeras Family Trust, of which the reporting person is the sole beneficiary. |