SEC Form 4 · accession 0001019687-15-001603
Medytox Solutions, Inc. · MMMS
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
William Forhan
Officer — CEO and Chairman · Director · 10% Owner
Period of report
Oct 1, 2012
Accepted (ET)
Apr 24, 2015 · 4:53 pm EDT
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0001374536
Table I — non-derivative securities
| Security | Date | Code | Shares | Price | A/D | Owned after | D/I | Nature of ownership |
|---|---|---|---|---|---|---|---|---|
| Common StockF1 | Dec 27, 2012 | J | 4,449,975 | — | D | 2,500,025 | D | |
| Common Stock | Dec 28, 2012 | G | 100,000 | $0.00 | D | 2,400,025 | D | |
| Common StockF2 | Dec 31, 2013 | J | 53,076 | — | A | 2,453,101 | D | |
| Restricted Stock | Mar 13, 2014 | A | 30,000 | $0.00 | A | 2,483,101 | D | |
| Common Stock | Sep 11, 2014 | J | 1,241,550 | $0.0001 | D | 1,241,551 | D | |
| Series C Preferred StockF1 | Dec 27, 2012 | J | 261,147 | — | A | 261,147 | D | |
| Series C Preferred StockF2 | Dec 31, 2013 | J | 261,147 | — | D | 0 | D |
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Options to Purchase Common StockF3 | $2.50 | Oct 1, 2012 | A | 1,000,000 | A | Oct 1, 2012 | Dec 21, 2017 | Common Stock | 1,000,000 | 1,000,000 | D |
| Options to Purchase Common StockF3 | $5.00 | Oct 1, 2012 | A | 1,000,000 | A | Oct 1, 2012 | Dec 31, 2017 | Common Stock | 1,000,000 | 1,000,000 | D |
| Options to Purchase Common StockF3 | $10.00 | Oct 1, 2012 | A | 1,000,000 | A | Oct 1, 2012 | Dec 31, 2022 | Common Stock | 1,000,000 | 1,000,000 | D |
Explanation of responses
- F1Represents shares of Common Stock cancelled by the Issuer and the issuance by Issuer of shares of Series C Preferred Stock.
- F2Represents shares of Common Stock issued upon conversion of shares of Series C Preferred Stock, pursuant to the terms of the Series C Preferred Stock
- F3Represents options to purchase shares of Common Stock granted in connection with the Reporting Person entering into an employment agreement with the Issuer. Pursuant to the terms of the Agreement for the Retirement as CEO and Release of any and all Claims, effective September 11, 2014, by and between the Issuer and the Reporting Person, the expiration date of the options was changed to August 31, 2016. The Reporting Person ceased serving as the Issuer's CEO and Chairman as of September 11, 2014.
- F4Pursuant to the terms of the Agreement for the Retirement as CEO and Release of any and all Claims, effective September 11, 2014, by and between the Issuer and the Reporting Person, the Reporting Person agreed to the cancellation of 1,241,550 shares of the Issuer's Common Stock. The value ascribed to the cancellation of such shares was the par value thereof.