1. Name and Address of Reporting Person * |
Â
CARSON RUSSELL L |
|
2. Date of Event Requiring Statement (Month/Day/Year) 09/24/2009 |
3. Issuer Name and Ticker or Trading Symbol SELECT MEDICAL HOLDINGS CORP [SEM]
|
C/O WELSH, CARSON, ANDERSON & STOWE, 320 PARK AVENUE, SUITE 2500 |
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
__X__ Director |
__X__ 10% Owner |
_____ Officer (give title below) |
_____ Other (specify below) |
|
|
5. If Amendment, Date Original Filed(Month/Day/Year)
|
NEW YORK, NY 10022 |
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 Beneficially Owned |
|
1.Title of Security (Instr. 4) |
2. Amount of Securities Beneficially Owned (Instr. 4) |
3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) |
4. Nature of Indirect Beneficial Ownership (Instr. 5) |
Common Stock
|
873,116
|
D
|
Â
|
Common Stock
|
24,257,155
|
I
|
By Welsh, Carson, Anderson & Stowe IX, L.P.
(1)
|
Common Stock
|
1,086,991
|
I
|
By WCAS Capital Partners IV, L.P.
(1)
|
|
1. Title of Derivative Security (Instr. 4) |
2. Date Exercisable and Expiration Date (Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) |
4. Conversion or Exercise Price of Derivative Security |
5. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 5) |
6. Nature of Indirect Beneficial Ownership (Instr. 5) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
Participating Preferred Stock
|
Â
(2)
|
Â
(2)
|
Common Stock
|
29,604,047
(3)
|
$
0
(2)
|
I
|
By Welsh, Carson, Anderson & Stowe IX, L.P.
(1)
|
Participating Preferred Stock
|
Â
(2)
|
Â
(2)
|
Common Stock
|
1,326,591
(3)
|
$
0
(2)
|
I
|
By WCAS Capital Partners IV, L.P.
(1)
|
Participating Preferred Stock
|
Â
(2)
|
Â
(2)
|
Common Stock
|
1,065,573
(3)
|
$
0
(2)
|
D
|
Â
|
* |
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). |
(1) |
The Reporting Person is a managing member of the respective sole general partners of Welsh, Carson, Anderson & Stowe IX, L.P. and WCAS Capital Partners IV, L.P. Pursuant to Instruction (5)(b)(iv) of Form 3, the Reporting Person has elected to report as indirectly beneficially owned the entire number of securities beneficially owned by each such entity. The Reporting Person disclaims beneficial ownership of any securities, and any proceeds thereof, that exceed his pecuniary interest therein and/or that are not actually distributed to him. |
(2) |
All shares of Participating Preferred Stock will automatically convert into Common Stock upon consummation of the Issuer's initial public offering. |
(3) |
Represents the number of shares of Common Stock to be received upon the conversion of the Participating Preferred Stock into Common Stock, assuming (i) an initial public offering price of $12.00 per share of Common Stock and (ii) a closing date of the initial public offering of September 30, 2009. |