SEC Form 4 · accession 0001185185-19-000334
PACIFIC HEALTH CARE ORGANIZATION INC · PFHO
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Kristina Kubota
Director
Period of report
May 14, 2018
Accepted (ET)
Mar 12, 2019 · 12:30 pm EDT
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 |
|---|---|---|---|---|---|---|---|---|
| CommonF1 | holding | — | — | — | 2,000 | D |
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Employee Stock OptionsF1 | $3.75 | May 14, 2018 | J | 4,000 | D | Aug 17, 2018 | Aug 17, 2022 | Common | 4,000 | 0 | D |
Explanation of responses
- F1Adjusted to reflect the four-shares-for-one-share forward split of the Company's common stock that took effect on April 5, 2018.
- F2On May 14, 2018, the Reporting Person executed a Stock Cancellation Agreement forfeiting unvested employee stock options she held to purchase 4,000 post-split shares of Common Stock of the Issuer (the "Forfeited Options") without any expectation to receive, and without any obligation on the Issuer to pay or grant, any cash, equity awards or other consideration presently or in the future with respect to the Forfeited Options.