UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549INITIAL 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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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | SEC 1473 (7-02) | ||
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 control number. |
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) |
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Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Series A-2 Preferred Stock | (2) | (2) | Common Stock | 855 | $ (2) | D | |
Series A-2 Preferred Stock | (2) | (2) | Common Stock | 845 | $ (2) | I | By Trust (3) |
Series B-1 Preferred Stock | (4) | (4) | Common Stock | 61,670 | $ (4) | I | By Trust (3) |
Series A-2 Preferred Stock | (2) | (2) | Common Stock | 62,857 | $ (2) | I | By Limited Liability Company (1) |
Series B-1 Preferred Stock | (4) | (2) | Common Stock | 327,728 | $ (4) | I | By Limited Liability Company (1) |
Wararnt (Right to Buy) | (5) | 02/13/2021 | Series B-1 Preferred Stock | 39,012 | $ 0.17 | I | By Limited Liability Company (1) |
Warrant (Right to Buy) | (5) | 07/12/2019 | Series B-1 Preferred Stock | 869 | $ 5.8667 | I | By Limited Liability Company (1) |
Warrant (Right to Buy) | (5) | 02/13/2021 | Series B-1 Preferred Stock | 11,703 | $ 0.17 | I | By Trust (3) |
Warrant (Right to Buy) | (5) | 07/12/2018 | Series B-1 Preferred Stock | 2,270 | $ 5.8667 | I | By Trust (3) |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Groos Thomas T. IONIA ST. SW, STE. 505 GRAND RAPIDS, MI 49503 |
X | X | ||
RT Groos, LLC IONIA ST. SW, STE. 505 GRAND RAPIDS, MI 49503 |
X | |||
Thomas T. Groos Revocable Trust IONIA ST. SW, STE. 505 GRAND RAPIDS, MI 49503 |
X |
/s/ Thomas T. Groos | 06/05/2017 | |
**Signature of Reporting Person | Date | |
/s/ Thomas T. Groos, Member | 06/05/2017 | |
**Signature of Reporting Person | Date | |
/s/ Thomas T. Groos, Trustee | 06/05/2017 | |
**Signature of Reporting Person | Date |
* | 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) | Shares held directly by RT Groos, LLC, over which Thomas T. Groos holds voting and dispositive power. |
(2) | Each share of Series A-2 Preferred Stock will be automatically converted into 0.715548 shares of Common Stock upon the closing of the Issuer's initial public offering of Common Stock and has no expiration date. |
(3) | Shares held directly by The Thomas T. Groos Revocable Trust, over which Thomas T. Groos holds voting and dispositive power. |
(4) | Each share of Series B-1 Preferred Stock will be automatically converted into 1 share of Common Stock upon the closing of the Issuer's initial public offering of Common Stock and has no expiration date. |
(5) | Immediate. |