Initial Statement of Beneficial Ownership (3)
May 19 2021 - 10:42AM
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
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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
*
HALPERN JOHN D |
2. Date of Event Requiring Statement (MM/DD/YYYY)
3/25/2021
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3. Issuer Name and Ticker or Trading Symbol
Brooklyn ImmunoTherapeutics, Inc. [BTX]
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(Last)
(First)
(Middle)
PO BOX 540 |
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)
PORTSMOUTH, NH 03802
(City)
(State)
(Zip)
| 5. If Amendment, Date Original Filed(MM/DD/YYYY)
| 6. Individual or Joint/Group Filing(Check Applicable Line)
___ Form filed by One Reporting Person
_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) | 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) |
Common Stock | 4094 | D (1) | |
Common Stock | 2300828 | I (2) | As trustee of family trust |
Common Stock | 30192 | I (2) | By LLC with independent manager |
Common Stock | 2870 | I (2) | By trust with independent trustee |
Common Stock | 2442323 | I (2) | By LLC with family member manager |
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 |
Explanation of Responses: |
(1) | Held by John D. Halpern |
(2) | The reporting persons disclaim beneficial ownership of these shares except to the extent of their pecuniary interest therein, if any. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
HALPERN JOHN D PO BOX 540 PORTSMOUTH, NH 03802 |
| X |
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Halpern Katherine H. PO BOX 540 PORTSMOUTH, NH 03802 |
| X |
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Signatures
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/s/ John D. Halpern | | 5/18/2021 |
**Signature of Reporting Person | Date |
/s/ Katherine H. Halpern | | 5/18/2021 |
**Signature of Reporting Person | Date |
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