Statement of Changes in Beneficial Ownership (4)
December 17 2019 - 4:59PM
Edgar (US Regulatory)
FORM 4
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
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
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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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Danenberg Noam |
2. Issuer Name and Ticker or Trading Symbol
Wize Pharma, Inc.
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WIZP
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
_____ Director _____ 10% Owner
__X__ Officer (give title below) _____ Other (specify below)
Chief Executive Officer |
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(Last)
(First)
(Middle)
C/O WIZE PHARMA, INC., 24 HANAGAR STREET |
3. Date of Earliest Transaction
(MM/DD/YYYY)
12/13/2019 |
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(Street)
HOD HASHARON, L3 4527708
(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 | 12/13/2019 | | C | | 752581 | A | (1) | 952681 | I | See Footnote (2) |
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) | 2. Conversion or Exercise Price of Derivative Security | 3. Trans. Date | 3A. Deemed Execution Date, if any | 4. Trans. Code
(Instr. 8) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5) | 6. Date Exercisable and Expiration Date | 7. Title and Amount of Securities Underlying Derivative Security
(Instr. 3 and 4) | 8. Price of Derivative Security
(Instr. 5) | 9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) | 10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) | 11. Nature of Indirect Beneficial Ownership (Instr. 4) |
| Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
| Warrants | $0.27 | 12/13/2019 | | J | | 1505162 | | (3) | 12/12/2024 | Common Stock | 1505162 | $0 | 1505162 | I | See Footnote (4) |
| Future Investment Rights | $0.27 | 12/13/2019 | | J | | | 31146 | 12/13/2019 | 12/12/2024 | Common Stock | 31146 | $0 | 94382 | I | See Footnote (4) |
| Explanation of Responses: |
| (1) | Outstanding debt converted at $0.27 per share. |
| (2) | 752,581 shares held by Mobigo Inc. and 200,100 previously held shares directly. |
| (3) | Exercisable five days following the public announcement of positive clinical data results for LO2A |
| (4) | Securities held by Mobigo Inc. |
Reporting Owners
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| Reporting Owner Name / Address | Relationships |
| Director | 10% Owner | Officer | Other |
Danenberg Noam
C/O WIZE PHARMA, INC.
24 HANAGAR STREET
HOD HASHARON, L3 4527708 |
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| Chief Executive Officer |
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Signatures
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| /s/ Or Eisenberg, Attorney-in-Fact | | 12/17/2019 |
| **Signature of Reporting Person | Date |