SEC Form 4 · accession 0001185185-16-005867
PACIFIC HEALTH CARE ORGANIZATION INC · PFHO
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Tom Kubota
Officer — CEO & President · Director · 10% Owner
Period of report
Nov 21, 2016
Accepted (ET)
Nov 22, 2016 · 2:26 pm EST
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0001138476
Table I — non-derivative securities
| Security | Date | Code | Shares | Price | A/D | Owned after | D/I | Nature of ownership |
|---|---|---|---|---|---|---|---|---|
| COMMON STOCKF2 | holding | — | — | — | 482,000 | D |
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Series A PreferredF2,F1 | $0.00 | Nov 21, 2016 | A | 1,000 | A | — | — | Common Stock | 1,000 | 1,000 | D |
Explanation of responses
- F1The Series A Preferred Stock converts into Common Stock of the Issuer on a 1:1 basis at any time at the election of the Reporting Person and has no expiration date.
- F2The Reporting Person holds the shares through the Tom Kubota Revocable Trust of 2013 (the "Trust"). The Reporting Person is the sole Trustee of the Trust. As such, the Reporting Person may be deemed to have voting and/or investment power over the shares held by the Trust and therefore may be deemed to be the beneficial owner of those shares.