Annual Statement of Changes in Beneficial Ownership (5)
February 14 2022 - 03:25PM
Edgar (US Regulatory)
FORM 5
[ ]
Check this box if no longer subject to Section 16. Form 4 or Form 5
obligations may continue. See Instruction 1(b).
[ ] Form 3 Holdings Reported
[X] Form 4 Transactions Reported
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL
OWNERSHIP OF SECURITIES
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OMB Number: 3235-0362
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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 * Curley
Tracy |
2. Issuer Name and Ticker or Trading
SymboliSpecimen Inc. [ISPC] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)_____
Director _____
10% Owner
__X__ Officer (give title
below) _____ Other
(specify below)
CFO & Treasurer |
(Last)
(First)
(Middle)
C/O ISPECIMEN INC., 450 BEDFORD STREET |
3. Statement for Issuer's Fiscal Year Ended
(MM/DD/YYYY)
12/31/2021
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(Street)
LEXINGTON, MA 02420
(City)
(State)
(Zip)
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4. 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 Acquired, Disposed of, or
Beneficially Owned
|
1.Title of Security
(Instr. 3) |
2. Trans. Date |
2A. Deemed Execution Date, if any |
3. Trans. Code
(Instr. 8) |
4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5) |
5. Amount of Securities Beneficially Owned Following
Reported Transaction(s)
(Instr. 3 and 4) |
6. Ownership Form: Direct (D) or Indirect (I)
(Instr. 4) |
7. Nature of Indirect Beneficial Ownership
(Instr. 4) |
Amount |
(A) or (D) |
Price |
Common Stock (1) |
7/30/2021 |
6/21/2021 |
A4 |
37879 (1) |
A |
(2) |
47879 (1) |
D |
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Table II - Derivative Securities Acquired, Disposed of, or
Beneficially Owned (e.g., puts, calls, warrants, options,
convertible securities)
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1. Title of Derivate Security
(Instr. 3) |
2. Conversion or Exercise Price of Derivative
Security |
3. Trans. Date |
3A. Deemed Execution Date, if any |
4. Trans. Code
(Instr. 8) |
5. Number of Derivative Securities Acquired (A) or
Disposed of (D)
(Instr. 3, 4 and 5) |
6. Date Exercisable and Expiration Date
(MM/DD/YYYY) |
7. Title and Amount of Securities Underlying
Derivative Security
(Instr. 3 and 4) |
8. Price of Derivative Security
(Instr. 5) |
9. Number of Derivative Securities Beneficially
Owned at End of Issuer's Fiscal Year
(Instr. 4) |
10. Ownership Form of Derivative Security: Direct
(D) or Indirect (I)
(Instr. 4) |
11. Nature of Indirect Beneficial Ownership
(Instr. 4) |
(A) |
(D) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
Explanation of
Responses: |
(1) |
Represents shares underlying
certain restricted stock units ("RSUs"), each of which is a
contingent right to receive one share of common stock at settlement
subject to the terms and conditions set forth in the award of such
RSUs by the Company to the Reporting Person pursuant to a
Restricted Stock Unit Award Agreement (the "RSU Agreement"). The
RSUs vest in five equal installments, on June 21, 2021, June 21,
2022, June 21, 2023, June 21, 2024 and June 21, 2025, subject to
the terms and conditions set forth in the RSU Agreement. 7,575 RSUs
were settled for shares of common stock on June 21, 2021, and the
Reporting Person was issued 7,575 shares of common
stock. |
(2) |
The RSUs were awarded as
compensation to the Reporting Person for her service as an officer
of the Company. |
Reporting
Owners
|
Reporting Owner Name / Address |
Relationships
|
Director |
10% Owner |
Officer |
Other |
Curley Tracy
C/O ISPECIMEN INC.
450 BEDFORD STREET
LEXINGTON, MA 02420 |
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CFO & Treasurer |
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Signatures
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/s/ Tracy Curley |
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2/14/2022 |
**Signature
of Reporting Person |
Date |
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