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) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
Series A Preferred Stock
|
10/14/2015 |
Â
(5)
|
Common Stock
|
1,111,111
(2)
(3)
|
$
(5)
|
I
|
By Network Medical Management, Inc.
(4)
|
Warrants to purchase Common Stock
|
10/14/2015 |
10/14/2020 |
Common Stock
|
1,111,111
(2)
(3)
|
$
9
|
I
|
By Network Medical Management, Inc.
(4)
|
* |
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) |
Reporting Person became a director of the Issuer on January 19, 2016. |
(2) |
Represents securities held by Network Medical Management, Inc. ("NMM") prior to Reporting Person becoming a director of the Issuer. |
(3) |
The Common Stock beneficially owned by NMM is comprised of (a) 1,111,111 shares of Common Stock that may be acquired upon conversion of Series A Preferred Stock that is currently convertible, and (b) 1,111,111 shares of Common Stock that may be acquired upon exercise of a currently exercisable Warrant. |
(4) |
These shares are owned directly by NMM, of which Reporting Person is a director, officer and shareholder. Reporting Person disclaims beneficial ownership of these shares except to the extent of his pecuniary interest therein, and the filing of this report is not an admission that Reporting Person is the beneficial owner of these shares for purposes of Section 16 or for any other purpose. |
(5) |
The Series A Preferred Stock is convertible into Common Stock, at the option of NMM, at any time after issuance at an initial conversion rate of one-for-one, subject to adjustment in the event of stock dividends, stock splits and certain other similar transactions. The Series A Preferred Stock is mandatorily convertible not sooner than the earlier to occur of (i) the later of (x) January 31, 2017 or (y) 60 days after the date on which the Issuer files its quarterly report on Form 10Q for the period ending September 30, 2016; or (ii) the date on which the Issuer received the written, irrevocable decision of NMM not to require a redemption of the Series A Preferred Stock, in the event that the Issuer engages in one or more transactions resulting in gross proceeds of not less than $5,000,000, not including the proceeds of the transaction with NMM. |