Statement of Changes in Beneficial Ownership (4)
June 04 2021 - 4:30PM
Edgar (US Regulatory)
FORM 4
[ ]
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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3235-0287
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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
*
MATHIESEN JEFFREY S |
2. Issuer Name and Ticker or Trading Symbol
NEUROONE MEDICAL TECHNOLOGIES Corp
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NMTC
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__X__ Director _____ 10% Owner _____ Officer (give title below) _____ Other (specify below)
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(Last)
(First)
(Middle)
7599 ANAGRAM DRIVE |
3. Date of Earliest Transaction
(MM/DD/YYYY)
6/2/2021 |
(Street)
EDEN PRAIRIE, MN 55344
(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
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security (Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code (Instr. 8)
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4. Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)
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7. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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Amount
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(A) or (D)
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Price
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Common Stock | 6/2/2021 | | A | | 4592 (1) | A | $0 | 36811 (2) | 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. 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 | 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 Following Reported Transaction(s) (Instr. 4) | 10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) | 11. Nature of Indirect Beneficial Ownership (Instr. 4) |
Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Option to Purchase Common Stock | $7.26 | 6/2/2021 | | A | | 4682 | | (3) | 6/2/2031 | Common Stock | 4682 | $0 | 4682 | D | |
Explanation of Responses: |
(1) | Represents a grant of restricted stock units, which vest in 12 equal monthly installments over a one-year period, with such vesting to occur at the end of each month. |
(2) | The share amount has been adjusted to reflect the reverse stock split effective on March 31, 2021 whereby each three shares issued and outstanding prior to the split were combined and converted into one share of common stock. |
(3) | The option vests in 12 equal monthly installments over a one-year period, with such vesting to occur at the end of each month. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
MATHIESEN JEFFREY S 7599 ANAGRAM DRIVE EDEN PRAIRIE, MN 55344 | X |
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Signatures
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/s/ Stephanie Swan, by Power of Attorney | | 6/4/2021 |
**Signature of Reporting Person | Date |
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