Annual Statement of Changes in Beneficial Ownership (5)
February 14 2022 - 6:44PM
Edgar (US Regulatory)
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
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Form 3 Holdings Reported
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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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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
*
Buttorff Leslie | 2. Issuer Name and Ticker or Trading SymbolPANACEA LIFE SCIENCES HOLDINGS, INC. [PLSH] |
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)
5910 SOUTH UNIVERSITY BLVD, C18-193 | 3. Statement for Issuer's Fiscal Year Ended (MM/DD/YYYY) 12/31/2021 |
(Street)
GREENWOOD VILLAGE, CO 80121
(City)
(State)
(Zip)
| 4. 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 Acquired, Disposed of, or Beneficially Owned
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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 | 12/21/2021 | | P | 500 | A | $0.9998 | 600399 | D | |
Common Stock | 12/21/2021 | | P | 1000 | A | $0.9024 | 601399 | D | |
Common Stock | 10/25/2021 | | D | 7321429 | D | (1) | 4047054 | I | Held by Quintel-MC, Incorporated |
Series C Preferred Stock | | | | | | | 1000000 | I | Held by Quintel-MC, Incorporated |
Series C-1 Preferred Stock | | | | | | | 10000 | I | Held by Quintel-MC, Incorporated |
Series C-2 Preferred Stock (2) | 10/25/2021 | | A | 100 | A | (3) | 100 | I | Held by Quintel-MC, Incorporated |
Series D Preferred Stock | | | | | | | 10000 | I | Held by J&N Real Estate Company LLC |
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) | The shares of common stock were cancelled in connection with the designation of 100 shares of Series C-2 Convertible Preferred Stock to Quintel-MC, Incorporated. |
(2) | The Series C-2 designates 100 shares for issuance, par value $0.0001 per share. Each share of Series C-2 is convertible into 73,215 shares of the Company's common stock and is entitled to vote on all matters submitted to the Company's stockholders on an as-converted basis. Other than the conversion and voting rights, there are no other preferences. |
(3) | The shares of preferred stock were acquired in connection with the cancellation of 7,321,429 shares of the Company's common stock that were held by Quintel-MC, Incorporated. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Buttorff Leslie 5910 SOUTH UNIVERSITY BLVD, C18-193 GREENWOOD VILLAGE, CO 80121 | X | X | Chief Executive Officer |
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Signatures
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/s/ Leslie Buttorff | | 2/14/2022 |
**Signature of Reporting Person | Date |
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