UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES 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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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | SEC 1473 (7-02) | ||
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. |
1. Title of Derivative Security (Instr. 4) |
2. Date Exercisable and Expiration Date (Month/Day/Year) |
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) |
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Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Stock Option (Right to Buy) | 03/31/2021 | 03/31/2031 | Common Stock | 12,194 (1) | $ 5.74 | D | |
Stock Option (Right to Buy) | (2) | 03/31/2031 | Common Stock | 4,878 (1) | $ 5.74 | D | |
Series 1d Preferred Stock | (3) | (3) | Common Stock | 55,078 (3) | $ (3) | D |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
WIERENGA WENDELL 3525 DEL MAR HEIGHTS RD., #332 SAN DIEGO, CA 92130 |
X |
/s/ Gerald T. Proehl, Attorney-in Fact | 08/12/2021 | |
**Signature of Reporting Person | Date |
* | 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). |
(1) | Shares reported reflect the 1 for 20.5 stock split effected July 1, 2021 (the "Stock Split"). |
(2) | Options vest in 12 equal monthly installments commencing January 1, 2021. |
(3) | The Series 1d Preferred Stock is convertible into shares of Common Stock at a conversion ratio equal to 80% of the offering price in connection with the Issuer's initial public offering ("IPO"). Upon filing of the Issuer's Restated Certificate of Incorporation in connection with the IPO, all shares of Series 1d Preferred Stock will be converted into 8,163 shares of Common Stock of the Issuer. The conversion ratio reflects the Stock Split. |
Remarks: Exhibit 24. Power of Attorney |