Initial Statement of Beneficial Ownership (3)
September 23 2021 - 4:01PM
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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Moghavem Pouya |
2. Date of Event Requiring Statement (MM/DD/YYYY)
4/1/2021
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3. Issuer Name and Ticker or Trading Symbol
GreenBox POS [GBOX]
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(Last)
(First)
(Middle)
3131 CAMINO DEL RIO NORTH, SUITE 1400 |
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director _____ 10% Owner ___X___ Officer (give title below) _____ Other (specify below) CBDO / |
(Street)
SAN DIEGO, CA 92108
(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 par value $0.001 | 110000 (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 Options | 6/22/2020 | 6/22/2025 | Common Stock par value $0.001 | 37996 (2) | $0.07 | D | |
Stock Options | 6/24/2020 | 6/24/2025 | Common Stock par value $0.001 | 38462 (3) | $0.065 | D | |
Stock Options | 12/1/2020 | 6/1/2026 | Common Stock par value $0.001 | 2475 (4) | $1.01 | D | |
Explanation of Responses: |
(1) | The Company effected a reverse stock split of 1:6 on February 17, 2021. As a result, Mr. Moghavem's 110,000 shares of common stock became 18,333 shares of common stock. |
(2) | The Company effected a reverse stock split of 1:6 on February 17, 2021. As a result, Mr. Moghavem's 37,996 stock options became 6,333 stock options. |
(3) | The Company effected a reverse stock split of 1:6 on February 17, 2021. As a result, Mr. Moghavem's 38,462 stock options became 6,410 stock options. |
(4) | The Company effected a reverse stock split of 1:6 on February 17, 2021. As a result, Mr. Moghavem's 2,475 stock options became 413 stock options. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Moghavem Pouya 3131 CAMINO DEL RIO NORTH SUITE 1400 SAN DIEGO, CA 92108 |
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| CBDO |
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Signatures
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/s/ Pouya Moghavem | | 9/22/2021 |
**Signature of Reporting Person | Date |
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