Statement of Changes in Beneficial Ownership (4)
October 27 2021 - 4:04PM
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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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
*
kotob Hassan |
2. Issuer Name and Ticker or Trading Symbol
BRAIN SCIENTIFIC INC.
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BRSF
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__X__ Director __X__ 10% Owner __X__ Officer (give title below) _____ Other (specify below) Chief Executive Officer |
(Last)
(First)
(Middle)
C/O BRAIN SCIENTIFIC INC., 125 WILBUR PLACE, SUITE 170 |
3. Date of Earliest Transaction
(MM/DD/YYYY)
10/1/2021 |
(Street)
BOHEMIA, NY 11716
(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 | 10/1/2021 | | A | | 7407934 | A | (1) | 7407934 | I | By Hassan Kotob Revocable Trust |
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 |
Stock Option (right to buy) | $0.35 | 10/1/2021 | | A | | 2502341 | | 10/1/2021 | 10/1/2031 | Common Stock | 2502341 | (2) | 2502341 | D | |
Stock Option (right to buy) | $0.39 | 10/21/2021 | | A | | 1218248 | | (3) | 10/21/2031 | Common Stock | 1218248 | $0 | 1218248 | D | |
Explanation of Responses: |
(1) | In connection with the closing of the transactions contemplated by the Agreement and Plan of Merger and Reorganization, dated as of June 11, 2021, by and among the Issuer, Piezo Motion Corp., a Delaware corporation ("Piezo"), and BRSF Acquisition Inc., a Delaware corporation and a wholly-owned subsidiary of the Issuer ("Merger Sub"), pursuant to which Merger Sub merged with and into Piezo (the "Merger"), with Piezo surviving as a wholly-owned subsidiary of the Issuer, these shares of common stock were received in exchange for 2,524,044 shares of common stock of Piezo. |
(2) | Received in connection with the Merger as part of the Merger consideration. |
(3) | The shares underlying this option vest as to 25% on 4/21/2022, with the remainder vesting in 18 equal monthly installments thereafter, beginning on 5/21/2022 and ending on 10/21/2023. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
kotob Hassan C/O BRAIN SCIENTIFIC INC. 125 WILBUR PLACE, SUITE 170 BOHEMIA, NY 11716 | X | X | Chief Executive Officer |
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Signatures
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/s/ Hassan Kotob | | 10/27/2021 |
**Signature of Reporting Person | Date |
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