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)
12/25/2022
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3. Issuer Name and Ticker or Trading Symbol
ELI LILLY & Co
[ LLY ]
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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) |
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EVP, HR & Diversity
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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 |
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| 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 |
4,100 |
D |
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| Common Stock |
90 |
I |
401(k) |
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 |
| Restricted Stock Unit |
03/01/2023 |
03/01/2023 |
Common Stock |
1,602 |
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D |
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| Restricted Stock Unit |
03/01/2025 |
03/01/2025 |
Common Stock |
2,403 |
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D |
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| Restricted Stock Unit |
11/01/2024 |
11/01/2024 |
Common Stock |
1,534 |
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D |
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| Restricted Stock Unit |
11/01/2026 |
11/01/2026 |
Common Stock |
2,300 |
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D |
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| Explanation of Responses: |
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| Remarks: |
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/s/ Jonathan Groff for Eric Dozier, pursuant to authorization attached |
01/03/2023 |
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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. |
LIMITED POWER OF ATTORNEY
For Managing Form ID and Executing Forms 3, 4 and 5
I hereby authorize and designate (i) Anat Hakim, Lilly Corporate Center, Indianapolis, Indiana, (ii) Christopher Anderson, Lilly Corporate Center, Indianapolis, Indiana, and (iii) Jonathan Groff, Lilly Corporate Center, Indianapolis, Indiana, each signing severally and not jointly, with full power of substitution, to take the following actions on my behalf regarding my transactions and holdings in the common stock and other equity securities of Eli Lilly and Company as required by Section 16 of the Securities Exchange Act of 1934 and the rules thereunder (collectively, "Securities Laws"):
1. as applicable, prepare, execute in my name and on my behalf, and submit to the United States Securities and Exchange Commission (the "SEC") a Form ID, Uniform Application for Access Codes to File on EDGAR and any other documents necessary or appropriate to obtain or maintain codes and passwords enabling me to make electronic filings with the SEC of reports required by the Securities Laws; and
2. sign and file with the SEC on my behalf Forms 3, 4, and 5 (including any amendments thereto).
The undersigned hereby agrees that each such attorney-in-fact may rely entirely on information furnished orally or in writing by or at my direction to the attorney-in-fact.
This authorization and designation shall remain in effect until a written revocation is signed by me and provided to Eli Lilly and Company and the attorneys-in-fact listed above.
IN WITNESS WHEREOF, the undersigned has caused this Limited Power of Attorney to be executed as of the date written below.
November 2, 2022
/s/ Eric Dozier
