Initial Statement of Beneficial Ownership (3)
April 07 2021 - 9:41AM
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
*
Sharon Simon |
2. Date of Event Requiring Statement (MM/DD/YYYY)
4/7/2021
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3. Issuer Name and Ticker or Trading Symbol
Microbot Medical Inc. [MBOT]
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(Last)
(First)
(Middle)
C/O MICROBOT MEDICAL INC., 25 RECREATION PARK DRIVE, UNIT 108 |
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director _____ 10% Owner ___X___ Officer (give title below) _____ Other (specify below) General Manager & CTO / |
(Street)
HINGHAM,, MA 02043
(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) |
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 (Right to Buy) | (1) | 8/13/2028 | Common Stock, par value $0.01 per share | 10000 | $9.00 | D | |
Stock Option (Right to Buy) | (2) | 8/12/2029 | Common Stock, par value $0.01 per share | 14170 | $5.95 | D | |
Explanation of Responses: |
(1) | The option vests as follows and in accordance with the terms of the Issuer's 2017 Equity Incentive Plan: (a) on February 13, 2019, the option vested and became exercisable with respect to 25% of the common stock; and (b) on a quarterly basis over the next 30 months, the option shall equally vest and become exercisable with respect to the remaining 75% of the common stock. |
(2) | The option vests as follows and in accordance with the terms of the Issuer's 2017 Equity Incentive Plan: (a) on February 12, 2020, the option vested and became exercisable with respect to 25% of the common stock; and (b) on a quarterly basis over the next 30 months, the option shall equally vest and become exercisable with respect to the remaining 75% of the common stock. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Sharon Simon C/O MICROBOT MEDICAL INC. 25 RECREATION PARK DRIVE, UNIT 108 HINGHAM,, MA 02043 |
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| General Manager & CTO |
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Signatures
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/s/ Simon Sharon | | 4/7/2021 |
**Signature of Reporting Person | Date |
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