Initial Statement of Beneficial Ownership (3)
April 11 2022 - 9:33AM
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
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Scipta Ellen |
2. Date of Event Requiring Statement (MM/DD/YYYY)
3/31/2022
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3. Issuer Name and Ticker or Trading Symbol
Fresh Vine Wine, Inc. [VINE]
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(Last)
(First)
(Middle)
505 HIGHWAY 169 N, SUITE 255 |
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director _____ 10% Owner ___X___ Officer (give title below) _____ Other (specify below) CFO / |
(Street)
PLYMOUTH, MN 55441
(City)
(State)
(Zip)
| 5. If Amendment, Date Original Filed(MM/DD/YYYY)
| 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 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 | 100000 (1) | D | |
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 |
Stock Option | (2) | 3/30/2032 | Common Stock | 200000 | $3.30 | D | |
Explanation of Responses: |
(1) | Represents a restricted stock grant with transfer and forfeiture restrictions on the shares that lapse as follows: 33,334 shares on March 30, 2022 (date of grant), 33,333 shares on March 30, 2023, and 33,333 shares on March 30, 2024. |
(2) | The options were granted pursuant to an agreement dated March 30, 2022 between the Company and the Reporting Person. Options to acquire 200,000 shares will vest in three installments of 66,667 on March 30, 2022, 66,666 on March 30, 2023, and 66,666 on March 30, 2024. The grant was approved in accordance with Rule 16b-3(d) of the Securities Exchange Act of 1934 (the "1934 Act"), and in accordance with Rule 16b-3(a) of the 1934 Act is exempt from Section 16(b) of the 1934 Act. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Scipta Ellen 505 HIGHWAY 169 N SUITE 255 PLYMOUTH, MN 55441 |
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| CFO |
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Signatures
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/s/ Ellen Scipta | | 4/5/2022 |
**Signature of Reporting Person | Date |
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. |
* | If the form is filed by more than one reporting person, see Instruction 5(b)(v). |
** | Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). |
Note: | File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. |
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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