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*
114 W 7TH STREET |
SUITE 240 |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 03/25/2024
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3. Issuer Name and Ticker or Trading Symbol
GREEN DOT CORP
[ GDOT ]
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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 |
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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Class A Common Stock |
20,735
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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 |
Explanation of Responses: |
Remarks: |
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/s/ Lina Davidian as attorney-in-fact for Robert C. Millard |
04/01/2024 |
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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
The undersigned as a Section 16 reporting person of Green
Dot Corporation (the "Company"), hereby constitutes and appoints
Amy Pugh, Lina Davidian and Jo Mann, and each of them, the
undersigned's true and lawful attorney-in-fact to:
(1) execute, deliver and file for and on behalf of the
undersigned, in the undersigned's capacity as an
officer and/or director of the Company, Forms 3, 4,
and 5 in accordance with Section 16(a) of the
Securities Exchange Act of 1934, as amended, and the
rules and regulations thereunder (the "Exchange Act");
(2) do and perform any and all acts for and on behalf of
the undersigned which may be necessary or desirable to
complete and execute any such Form 3, 4, or 5,
complete and execute any amendment or amendments
thereto, and timely file such form with the United
States Securities and Exchange Commission and any
stock exchange or similar authority;
(3) seek or obtain, as the undersigned's representative
and on the undersigned's behalf, information on
transactions in the Company's securities from any
third party, including brokers, employee benefit plan
administrators and trustees, and the undersigned
hereby authorizes any such person to release any such
information to the undersigned and approves and
ratifies any such release of information; and
(4) take any other action of any type whatsoever in
connection with the foregoing which, in the opinion of
such attorney-in-fact, may be of benefit to, in the
best interest of, or legally required by, the
undersigned, it being understood that the documents
executed by such attorney-in-fact on behalf of the
undersigned pursuant to this Power of Attorney shall
be in such form and shall contain such terms and
conditions as such attorney-in-fact may approve in
such attorney-in-fact's discretion.
The undersigned hereby grants to each such attorney-in-fact
full power and authority to do and perform any and every act and
thing whatsoever requisite, necessary, or proper to be done in
the exercise of any of the rights and powers herein granted, as
fully to all intents and purposes as the undersigned might or
could do if personally present, with full power of substitution
or revocation, hereby ratifying and confirming all that such
attorney-in-fact, or such attorney-in-fact's substitute or
substitutes, shall lawfully do or cause to be done by virtue of
this Power of Attorney and the rights and powers herein granted.
The undersigned acknowledges that the foregoing
attorneys-in-fact, in serving in such capacity at the request of
the undersigned, are not assuming, nor is the Company assuming,
any of the undersigned's responsibilities to comply with
Section 16 of the Exchange Act. The undersigned further
acknowledges and agrees that the attorney-in-fact and the
Company are relying on written and oral information provided by
the undersigned to complete such forms and the undersigned is
responsible for reviewing the completed forms prior to their
filing. The attorney-in-fact and the Company are not
responsible for any errors or omissions in such filings. The
attorney-in-fact and the Company are not responsible for
determining whether or not the transactions reported could be
matched with any other transactions for the purpose of
determining liability for short-swing profits under
Section 16(b).
This Power of Attorney shall remain in full force and
effect until the undersigned is no longer required to file Forms
3, 4, and 5 with respect to the undersigned's holdings of and
transactions in securities issued by the Company, unless earlier
revoked by the undersigned in a signed writing delivered to the
Company and the foregoing attorneys-in-fact. This Power of
Attorney revokes all previous powers of attorney with respect to
the subject matter of this Power of Attorney.
IN WITNESS WHEREOF, the undersigned has caused this Power
of Attorney to be executed as of March 25, 2024.
/s/ Robert Millard
Name: Robert Millard