Statement of Changes in Beneficial Ownership (4)
May 28 2021 - 5:29PM
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
*
Jacoby Michael Z |
2. Issuer Name and Ticker or Trading Symbol
Broad Street Realty, Inc.
[
BRST
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__X__ Director _____ 10% Owner __X__ Officer (give title below) _____ Other (specify below) Chief Executive Officer |
(Last)
(First)
(Middle)
C/O BROAD STREET REALTY, INC., 7250 WOODMONT AVE, SUITE 350 |
3. Date of Earliest Transaction
(MM/DD/YYYY)
5/26/2021 |
(Street)
BETHESDA, MD 20814
(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 | 5/26/2021 | | A | | 6813 (1) | A | (1)(2) | 2150492 | 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 |
Explanation of Responses: |
(1) | Received in exchange for membership interests in BSV Cromwell Parent LLC ("Cromwell"), pursuant to the previously disclosed Agreement and Plan of Merger (the "Cromwell Merger Agreement"), dated as of May 28, 2019, as amended on Nov. 27, 2019 and Dec. 27, 2019, by and among Cromwell, Broad Street Realty, Inc. (the "Issuer"), Broad Street Operating Partnership, LP and a subsidiary. Upon the closing of the transactions contemplated by the Cromwell Merger Agreement (the "Cromwell Merger"), the membership interests that were then outstanding were converted into the right to receive shares of the Issuer's common stock. |
(2) | As of the date immediately prior to the effective time of the Cromwell Merger, the last reported sales price of the Issuer's common stock on the OTC Pink Market was $1.25 per share. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Jacoby Michael Z C/O BROAD STREET REALTY, INC. 7250 WOODMONT AVE, SUITE 350 BETHESDA, MD 20814 | X |
| Chief Executive Officer |
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Signatures
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/s/ Andrew P. Campbell as attorney-in-fact for Michael Z. Jacoby | | 5/28/2021 |
**Signature of Reporting Person | Date |
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