# EDGAR Filing Document

**Accession Number:** 0001795057
**File Stem:** 0001104659-23-027835
**Filing Date:** 2023-3
**Character Count:** 10350
**Document Hash:** 8409dc1e0897d1b4481472509127ce41
**Contains OCR:** False
**Source Format:** 

## Filing Content

## Filing Summary
**0001104659-23-027835.hdr.sgml**: 20230302

**ACCESSION NUMBER**: 0001104659-23-027835

**CONFORMED SUBMISSION TYPE**: 4

**PUBLIC DOCUMENT COUNT**: 1

**CONFORMED PERIOD OF REPORT**: 20230228

**FILED AS OF DATE**: 20230302

**DATE AS OF CHANGE**: 20230302

**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** UAW GM RETIREES MEDICAL BENEFITS PLAN
- **CENTRAL INDEX KEY:** 0001795050
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 4
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 814-01393
- **FILM NUMBER:** 23698018

**BUSINESS ADDRESS:**
- **STREET 1:** 200 WALKER STREET
- **CITY:** DETROIT
- **STATE:** MI
- **ZIP:** 48207
- **BUSINESS PHONE:** 313-324-5928

**MAIL ADDRESS:**
- **STREET 1:** 200 WALKER STREET
- **CITY:** DETROIT
- **STATE:** MI
- **ZIP:** 48207
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** UAW Ford Retirees Medical Benefits Plan
- **CENTRAL INDEX KEY:** 0001795052
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 4
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 814-01393
- **FILM NUMBER:** 23698019

**BUSINESS ADDRESS:**
- **STREET 1:** 200 WALKER STREET
- **CITY:** DETROIT
- **STATE:** MI
- **ZIP:** 48207
- **BUSINESS PHONE:** 313-324-5928

**MAIL ADDRESS:**
- **STREET 1:** 200 WALKER STREET
- **CITY:** DETROIT
- **STATE:** MI
- **ZIP:** 48207

**FORMER NAME:**
- **FORMER CONFORMED NAME:** UAW Ford Retireees Medical Benefits Plan
- **DATE OF NAME CHANGE:** 20191125
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** UAW Chrysler Retirees Medical Benefits Plan
- **CENTRAL INDEX KEY:** 0001795057
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 4
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 814-01393
- **FILM NUMBER:** 23698020

**BUSINESS ADDRESS:**
- **STREET 1:** 200 WALKER STREET
- **CITY:** DETROIT
- **STATE:** MI
- **ZIP:** 48207
- **BUSINESS PHONE:** 313-324-5928

**MAIL ADDRESS:**
- **STREET 1:** 200 WALKER STREET
- **CITY:** DETROIT
- **STATE:** MI
- **ZIP:** 48207

**FORMER NAME:**
- **FORMER CONFORMED NAME:** UAW Chrysler Retireees Medical Benefits Plan
- **DATE OF NAME CHANGE:** 20191125
**ISSUER**: 

**COMPANY DATA:**
- **COMPANY CONFORMED NAME:** Kayne DL 2021, Inc.
- **CENTRAL INDEX KEY:** 0001850787
- **IRS NUMBER:** 862440860
- **STATE OF INCORPORATION:** DE
- **FISCAL YEAR END:** 1231

**BUSINESS ADDRESS:**
- **STREET 1:** 811 MAIN STREET, 14TH FLOOR
- **CITY:** HOUSTON
- **STATE:** TX
- **ZIP:** 77002
- **BUSINESS PHONE:** 713-493-2020

**MAIL ADDRESS:**
- **STREET 1:** 811 MAIN STREET, 14TH FLOOR
- **CITY:** HOUSTON
- **STATE:** TX
- **ZIP:** 77002

### UNITED STATES SECURITIES AND EXCHANGE COMMISSION
**Washington, D.C. 20549**

## FORM 4

### STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

[ ] Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).

[ ] Check this box to indicate that a transaction was made pursuant to a contract, instruction or written plan for the purchase or sale of equity securities of the issuer that is intended to satisfy the affirmative defense conditions of Rule 10b5-1(c). See Instruction 10.

---

| | | |
|:---|:---|:---|
| **1. Name and Address of Reporting Person**<sup>*</sup><br>UAW Chrysler Retirees Medical Benefits Plan<br><sub>(Last) (First) (Middle)</sub><br>C/O UAW RETIREE MEDICAL BENEFITS TRUST,<br>1155 BREWERY PARK BLVD., SUITE 400<br><sub>(Street)</sub><br>DETROIT, MI 48207<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2023-02-28 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[ ] Director [X] 10% Owner<br>[ ] Officer (give title below) [ ] Other (specify below)<br>_ _ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>Kayne DL 2021, Inc. [ NONE ] | **4. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  | **6. Individual or Joint/Group Filing (Check Applicable Line)**<br>[ ] Form filed by One Reporting Person<br>[X] Form filed by More than One Reporting Person |

---

---

| | | |
|:---|:---|:---|
| **1. Name and Address of Reporting Person**<sup>*</sup><br>UAW Ford Retirees Medical Benefits Plan<br><sub>(Last) (First) (Middle)</sub><br>C/O UAW RETIREE MEDICAL BENEFITS TRUST,<br>1155 BREWERY PARK BLVD., SUITE 400<br><sub>(Street)</sub><br>DETROIT, MI 48207<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2023-02-28 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[ ] Director [X] 10% Owner<br>[ ] Officer (give title below) [ ] Other (specify below)<br>_ _ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>Kayne DL 2021, Inc. [ NONE ] | **4. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  | **6. Individual or Joint/Group Filing (Check Applicable Line)**<br>[ ] Form filed by One Reporting Person<br>[X] Form filed by More than One Reporting Person |

---

---

| | | |
|:---|:---|:---|
| **1. Name and Address of Reporting Person**<sup>*</sup><br>UAW GM RETIREES MEDICAL BENEFITS PLAN<br><sub>(Last) (First) (Middle)</sub><br>C/O UAW RETIREE MEDICAL BENEFITS TRUST,<br>1155 BREWERY PARK BLVD., SUITE 400<br><sub>(Street)</sub><br>DETROIT, MI 48207<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2023-02-28 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[ ] Director [X] 10% Owner<br>[ ] Officer (give title below) [ ] Other (specify below)<br>_ _ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>Kayne DL 2021, Inc. [ NONE ] | **4. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  | **6. Individual or Joint/Group Filing (Check Applicable Line)**<br>[ ] Form filed by One Reporting Person<br>[X] Form filed by More than One Reporting Person |

---

## Table I - Non-Derivative Securities

---

|  |  |  |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| 1. Title of Security | 2. Transaction Date | 2A. Deemed Execution Date | 3. Transaction Code (V) | 3. Transaction Code (V) | 4. Securities Acquired (A) or Disposed of (D) | 4. Securities Acquired (A) or Disposed of (D) | 4. Securities Acquired (A) or Disposed of (D) | 5. Amount of Securities Beneficially Owned | 6. Ownership Form | 7. Nature of Indirect Beneficial Ownership |
| 1. Title of Security | 2. Transaction Date | 2A. Deemed Execution Date | Code | V | Amount | (A) or (D) | Price | 5. Amount of Securities Beneficially Owned | 6. Ownership Form | 7. Nature of Indirect Beneficial Ownership |
| Common Stock | 2023-02-28 |  | P |  | 921.744 | A | $5236.00 | 4956.295 | D<sup>(1)</sup> |  |
| Common Stock | 2023-02-28 |  | P |  | 1436.975 | A | $5236.00 | 7726.736 | D<sup>(2)</sup> |  |
| Common Stock | 2023-02-28 |  | P |  | 2368.172 | A | $5236.00 | 12733.865 | D<sup>(3)</sup> |  |

---

## Table II - Derivative Securities

---

|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| 1. Title of Derivative Security | 2. Conversion or Exercise Price | 3. Transaction Date | 3A. Deemed Execution Date | 4. Transaction Code (V) | 4. Transaction Code (V) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) | 6. Date Exercisable and Expiration Date | 6. Date Exercisable and Expiration Date | 7. Title and Amount of Underlying Securities | 7. Title and Amount of Underlying Securities | 8. Price of Derivative Security | 9. Number of Derivative Securities Beneficially Owned | 10. Ownership Form | 11. Nature of Indirect Beneficial Ownership |
| 1. Title of Derivative Security | 2. Conversion or Exercise Price | 3. Transaction Date | 3A. Deemed Execution Date | Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | 8. Price of Derivative Security | 9. Number of Derivative Securities Beneficially Owned | 10. Ownership Form | 11. Nature of Indirect Beneficial Ownership |
|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |

---

### Footnotes:

(1) These shares of common stock (the "Shares") of Kayne DL 2021, Inc. (the "Issuer") are owned directly by the UAW Chrysler Retirees Medical Benefits Plan, as established and maintained by the UAW Chrysler Retirees Employees' Beneficiary Association, an employee organization within the meaning of Section 3(4) of the Employee Retirement Income Security Act of 1974, as amended ("ERISA") under the UAW Retiree Medical Benefits Trust, organized as a 501(c)(9) Voluntary Employee Beneficiary Association (the "UAW RMBT").

(2) These Shares of the Issuer are owned directly by the UAW Ford Retirees Medical Benefits Plan, as established and maintained by the UAW Ford Retirees Employees' Beneficiary Association, an employee organization within the meaning of Section 3(4) of ERISA under the UAW RMBT.

(3) These Shares of the Issuer are owned directly by the UAW GM Retirees Medical Benefits Plan, as established and maintained by the UAW GM Retirees Employees' Beneficiary Association, an employee organization within the meaning of Section 3(4) of ERISA under the UAW RMBT.

**Signature:** UAW CHRYSLER RETIREES MEDICAL BENEFITS PLAN, By: /s/ Garon Meikle, Chief Financial Officer  
**Date:** 2023-03-02

**Signature:** UAW FORD RETIREES MEDICAL BENEFITS PLAN, By: /s/ Garon Meikle, Chief Financial Officer  
**Date:** 2023-03-02

**Signature:** UAW GM RETIREES MEDICAL BENEFITS PLAN, By: /s/ Garon Meikle, Chief Financial Officer  
**Date:** 2023-03-02

### Remarks:

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 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).

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.**