Initial Statement of Beneficial Ownership (3)
October 12 2018 - 7:55PM
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
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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
*
Ezralow Bryan
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2. Date of Event Requiring Statement (MM/DD/YYYY)
10/2/2018
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3. Issuer Name
and
Ticker or Trading Symbol
Jaguar Health, Inc. [JAGX]
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(Last)
(First)
(Middle)
23622 CALABASAS ROAD, SUITE 200,
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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)
CALABASAS, CA 91302
(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)
___ Form filed by One Reporting Person
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X
_ Form filed by More than One Reporting Person
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Table I - Non-Derivative Securities Beneficially Owned
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1.Title of Security
(Instr. 4)
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2. Amount of Securities Beneficially Owned
(Instr. 4)
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3. Ownership Form: Direct (D) or Indirect (I)
(Instr. 5)
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4. Nature of Indirect Beneficial Ownership
(Instr. 5)
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Common Stock
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416667
(1)
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I
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By EZ MM&B Holdings, LLC
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Common Stock
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1250000
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I
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By Bryan Ezralow 1994 Trust u/t/d December 22, 1994
(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. 4)
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2. Date Exercisable and Expiration Date
(MM/DD/YYYY)
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3. Title and Amount of Securities Underlying Derivative Security
(Instr. 4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
(Instr. 5)
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6. Nature of Indirect Beneficial Ownership
(Instr. 5)
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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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Explanation of Responses:
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(1)
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The reporting person disclaims beneficial ownership of these shares except to the extent of the reporting person's pecuniary interest therein, and the inclusion of these shares in this report shall not be deemed an admission of beneficial ownership of all of the reported shares for purposes of Section 16 or for any other purpose.
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(2)
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These shares are owned directly by the Bryan Ezralow 1994 Trust u/t/d December 22, 1994, a ten percent owner of the issuer, and indirectly by Bryan Ezralow as trustee of such Trust.
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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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Ezralow Bryan
23622 CALABASAS ROAD, SUITE 200
CALABASAS, CA 91302
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X
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Bryan Ezralow 1994 Trust dated December 22, 1994
23622 CALABASAS ROAD
SUITE 200
CALABASAS, CA 91302
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X
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Signatures
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/s/ Bryan Ezralow
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10/12/2018
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**
Signature of Reporting Person
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Date
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/s/ Bryan Ezralow, Trustee of Bryan Ezralow 1994 Trust dated December 22, 1994
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10/12/2018
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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 5(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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