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 | ||||
Convertible Promissory Note | (2) | (2) | Common Stock | 115,559 | $ (2) | D | |
Common Stock warrant (right to buy) | (3) | 02/11/2023 | Common Stock | 5,818 | $ 2.75 | D | |
Common Stock warrant (right to buy) | (4) | 02/12/2023 | Common Stock | 363,636 | $ 0.0003 | D |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Vajdic Branislav 2118 WALSH AVE, SUITE 210 SANTA CLARA, CA 95050 |
X | Chief Executive Officer |
/s/ Branislav Vajdic | 11/10/2021 | |
**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) | 32,727 shares are held in the name of his spouse, Marijana Rakic. |
(2) | Represents $485,347.80 of outstanding principal and interest calculated through November 10, 2021. The note will convert into 115,559 shares of Common Stock upon the closing of the Issuer's initial public offering of Common Stock (the "IPO"). |
(3) | All of the shares subject to the warrant are fully vested and exercisable as of the date hereof. |
(4) | The shares subject to the warrant are exercisable upon the earliest to occur of several events, including the closing of the IPO and the Issuer having a market capitalization of at least $50,000,000 for five consecutive business days. |