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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1. Name and Address of Reporting Person*
Czerney Kevin

(Last) (First) (Middle)
C/O DENTSPLY SIRONA INC
13320-B BALLANTYNE CORPORATE PLACE

(Street)
CHARLOTTE NC 28277

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
11/07/2024
3. Issuer Name and Ticker or Trading Symbol
DENTSPLY SIRONA Inc. [ XRAY ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director 10% Owner
checkbox checked Officer (give title below) Other (specify below)
VP, Chief Accounting Officer
5. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
checkbox checked 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 5,844.653 D
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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: 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
Stock Option (Right to Buy) (1) 11/16/2032 Common Stock 4,200 30.6 D
Stock Option (Right to Buy) (2) 03/03/2033 Common Stock 4,000 38.74 D
Phantom Stock (Dentsply Supplemental Savings Plan) DSSP (3) (3) Common Stock 322.488 (3) D
Phantom Stock (Supplemental Executive Retirement Plan) SERP (4) (4) Common Stock 377 (4) D
Explanation of Responses:
1. Stock options vest in annual one-third (1/3) increments over a three (3) year period ending November 16, 2025.
2. Stock options vest in annual one-third (1/3) increments over a three (3) year period ending March 3, 2026.
3. Each share of phantom stock is the economic equivalent of one share of common stock. The shares of phantom stock become payable in common stock upon the reporting person's termination of employment.
4. The shares of phantom stock become payable in common stock upon the reporting persons termination of employment.
Remarks:
Exhibit 24 - Power of Attorney
s/ Dane Baumgardner, Attorney-In-Fact for Kevin Czerney 11/12/2024
** 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.
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