Initial Statement of Beneficial Ownership (3)
March 09 2021 - 05:35PM
Edgar (US Regulatory)
FORM 3
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UNITED STATES SECURITIES AND EXCHANGE
COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP
OF SECURITIES
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OMB
APPROVAL
OMB Number: 3235-0104
Estimated average burden
hours per response... 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 * Cozad Jeffrey
Alley |
2. Date of Event Requiring Statement
(MM/DD/YYYY)
2/26/2021
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3. Issuer Name and Ticker or Trading
Symbol Medicine Man Technologies, Inc. [SHWZ] |
(Last)
(First)
(Middle)
4740 W. MOCKINGBIRD LANE, P.O. BOX 195579 |
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)_____
Director ___X___
10% Owner
_____ Officer (give title
below) _____
Other (specify below)
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(Street)
DALLAS, TX 75209
(City)
(State)
(Zip)
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5. 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 |
Table I - Non-Derivative Securities Beneficially
Owned
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1.Title of Security
(Instr. 4) |
2. Amount of Securities Beneficially Owned
(Instr. 4) |
3. Ownership Form: Direct (D) or Indirect (I)
(Instr. 5) |
4. Nature of Indirect Beneficial Ownership
(Instr. 5) |
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible
securities)
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1. Title of Derivate Security
(Instr. 4) |
2. Date Exercisable and Expiration Date
(MM/DD/YYYY) |
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 Cumulative Convertible Preferred Stock |
(1) |
(1) |
Common Stock |
19375000 (2) |
$1.20 (3) |
I |
See Footnote (4) |
Explanation of
Responses: |
(1) |
The shares of Series A
Cumulative Convertible Preferred Stock (the "Series A Preferred
Shares") are convertible into shares of the common stock (the
"Common Shares") of Medicine Man Technologies, Inc. (the "Company")
upon the events specified in the Company's Certificate of
Designation of Series A Cumulative Convertible Preferred Stock (the
"Certificate of Designation"). The Series A Preferred Shares have
no expiration date. |
(2) |
Represents the number of
Common Shares issuable upon conversion of the Series A Preferred
Shares on the date of event requiring this report. Each Series A
Preferred Share shall be convertible into that number of Common
Shares equal to the preference amount (initially $1,000) plus any
accrued dividends with respect to such share, divided by the
conversion price (initially $1.20), subject to adjustment as set
forth in the Certificate of Designation. The Series A Preferred
Shares earn a cumulative dividend of 8% per annum. |
(3) |
Subject to adjustment, as
described in the Certificate of Designation. |
(4) |
CRW Capital Cann Holdings,
LLC (the "Holder") is the record holder of the reported shares. Mr.
Cozad is a manager of CRW Capital, LLC, which is the sole manager
of the Holder. Mr. Cozad disclaims beneficial ownership of the
reported shares except to the extent of his pecuniary interest
therein. |
Reporting
Owners
|
Reporting Owner Name / Address |
Relationships
|
Director |
10% Owner |
Officer |
Other |
Cozad Jeffrey Alley
4740 W. MOCKINGBIRD LANE
P.O. BOX 195579
DALLAS, TX 75209 |
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X |
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Signatures
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/s/ Jeffrey A. Cozad |
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3/9/2021 |
**Signature of
Reporting Person |
Date |
Medicine Man Technologies (QX) (USOTC:SHWZ)
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