Initial Statement of Beneficial Ownership (3)
April 06 2022 - 2:16PM
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
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CAO MICHAEL HANH |
2. Date of Event Requiring Statement (MM/DD/YYYY)
3/31/2022
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3. Issuer Name and Ticker or Trading Symbol
Spine Injury Solutions, Inc [SPIN]
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(Last)
(First)
(Middle)
C/O SPINE INJURY SOLUTIONS, INC., 600 ANTON BOULEVARD, SUITE 1100 |
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
__X__ Director ___X___ 10% Owner _____ Officer (give title below) _____ Other (specify below)
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(Street)
COSTA MESA, CA 92626
(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 |
Series A Convertible Preferred Stock | (1) | (1) | Common Stock | 51507749 (2) | (1) | I | By Spouse |
Series A Convertible Preferred Stock | (1) | (1) | Common Stock | 128769372 (3) | (1) | I (4) | By B&B Investment Holding LLC |
Explanation of Responses: |
(1) | Each share of Series A Convertible Preferred Stock has no expiration date and is automatically convertible into 53.97561 shares of common stock upon obtaining shareholder and regulatory approvals and the Issuer's filing a certificate of amendment to the certificate of incorporation authorizing a sufficient number of shares of common stock to permit a full conversion of all issued and outstanding Series A Preferred Stock. Each share of Series A Convertible Preferred Stock is entitled to receive dividends and vote on an "as converted" basis with the common stock. |
(2) | Based on 954,277 shares of Series A Convertible Preferred Stock owned by the Reporting Person's spouse. |
(3) | Based on 2,385,692 shares of Series A Convertible Preferred Stock owned by B&B Investment Holding LLC. |
(4) | The Reporting Person is the manager of B&B Investment Holding LLC, has voting control over shares owned by B&B Investment Holding LLC, and may be deemed to have indirect beneficial ownership of all or a portion of the securities owned directly by B&B Investment Holding LLC, but disclaims beneficial ownership of the reported securities except to the extent of his pecuniary interest therein. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
CAO MICHAEL HANH C/O SPINE INJURY SOLUTIONS, INC. 600 ANTON BOULEVARD, SUITE 1100 COSTA MESA, CA 92626 | X | X |
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Signatures
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/s/ Michael Cao | | 4/6/2022 |
**Signature of Reporting Person | Date |
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. |
* | If the form is filed by more than one reporting person, see Instruction 5(b)(v). |
** | Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). |
Note: | File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. |
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB control number. |
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