Statement of Changes in Beneficial Ownership (4)
May 08 2018 - 3:49PM
Edgar (US Regulatory)
FORM 4
[ ]
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b).
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0287
Estimated average burden
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0.5
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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
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Yazbeck Daniel, Rida
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2. Issuer Name
and
Ticker or Trading Symbol
MyDx, Inc.
[
MYDX
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__
X
__ Director
__
X
__ 10% Owner
__
X
__ Officer (give title below)
_____ Other (specify below)
Chairman of the Board and CEO
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(Last)
(First)
(Middle)
6335 FERRIS SQUARE, SUITE B
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3. Date of Earliest Transaction
(MM/DD/YYYY)
6/30/2017
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(Street)
SAN DIEGO, CA 92121
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
_
X
_ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security
(Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code
(Instr. 8)
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4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)
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7. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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Amount
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(A) or (D)
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Price
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Common Stock
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5/7/2018
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5/7/2018
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J
(1)
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1750000000
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A
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(1)
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1789351606
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I
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See Footnote
(2)
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Table II - Derivative Securities Beneficially Owned (
e.g.
, puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 3)
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2. Conversion or Exercise Price of Derivative Security
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3. Trans. Date
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3A. Deemed Execution Date, if any
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4. Trans. Code
(Instr. 8)
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5. Number of Derivative Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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6. Date Exercisable and Expiration Date
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7. Title and Amount of Securities Underlying Derivative Security
(Instr. 3 and 4)
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8. Price of Derivative Security
(Instr. 5)
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9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4)
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10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4)
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11. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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(A)
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(D)
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Date Exercisable
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Expiration Date
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Title
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Amount or Number of Shares
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Preferred Stock (Series B Convertible)
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$0.0001
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6/30/2017
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6/30/2017
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J
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100000
(3)
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12/23/2016
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(3)
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Common Stock
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1000000000
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$0.50
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200000
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I
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YCIG, Inc.
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Preferred Stock (Series B Convertible)
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$0.0001
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5/7/2018
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5/7/2018
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C
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175000
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12/23/2016
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(1)
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Common Stock
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1750000000
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(1)
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25000
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I
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YCIG, Inc.
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Explanation of Responses:
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(1)
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On May 7, 2018, Mr. Yazbeck converted 175,000 shares of Series B Convertible Preferred Stock into shares of Common Stock via a cashless conversion of the stated value of $1.00 per Series B share divided by a conversion price of $0.0001 per share for an issuance of 1,750,000,000 shares of Common Stock.
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(2)
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Beneficial ownership of Daniel R. Yazbeck, directly and indirectly, as of the date of the filing of this Form 4 consists of 10,000 shares held directly by Mr. Yazbeck, 9,132,500 shares held by seven trusts for which Mr. Yazbeck serves as trustee, and 1,780,000,000 shares held by Mr. Yazbeck and YCIG, Inc. (an entity over whose securities Mr. Yazbeck has sole voting and sole investment control).
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(3)
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On June 30, 2017, Mr. Yazbeck sold 100,000 shares of Series B Preferred for gross proceeds of $50,000.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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Yazbeck Daniel, Rida
6335 FERRIS SQUARE, SUITE B
SAN DIEGO, CA 92121
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X
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X
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Chairman of the Board and CEO
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Signatures
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/s/ Daniel Yazbeck
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5/8/2018
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 4(b)(v).
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**
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Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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Note:
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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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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.
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