SEC Form 5 · accession 0001140361-16-052240
VIVOS INC · RDGL
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
James C Katzaroff
Officer — Chief Executive Officer · Director
Period of report
Dec 31, 2015
Accepted (ET)
Feb 12, 2016 · 4:09 pm EST
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0001449349
Table I — non-derivative securities
| Security | Date | Code | Shares | Price | A/D | Owned after | D/I | Nature of ownership |
|---|---|---|---|---|---|---|---|---|
| Common Stock | holding | — | — | — | 3,611,834 | D | ||
| Common Stock | holding | — | — | — | 54,000 | I | By Spouse |
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Series A Convertible Preferred StockF2,F1 | $0.005 | Jun 17, 2015 | A | 600 | A | Dec 4, 2015 | — | Common Stock | 600,000 | 116,740 | D |
| Series A Convertible Preferred StockF2,F1 | $0.005 | Aug 21, 2015 | A | 240 | A | Dec 4, 2015 | — | Common Stock | 240,000 | 116,740 | D |
| Series A Convertible Preferred StockF2,F1 | $0.005 | Sep 4, 2015 | A | 400 | A | Dec 4, 2015 | — | Common Stock | 400,000 | 116,740 | D |
| Convertible Promissory NoteF3 | — | Dec 4, 2015 | C | — | A | Sep 4, 2015 | Dec 31, 2015 | (see footnote) | — | 0 | D |
| Series A Convertible Preferred StockF4,F1 | $0.005 | Dec 4, 2015 | C | 5,000 | A | Dec 4, 2015 | — | Common Stock | 5,000,000 | 116,740 | D |
| Stock Options | $0.15 | holding | — | — | — | Nov 15, 2013 | Feb 11, 2023 | Common Stock | 3,250,000 | 3,350,000 | D |
| Stock Options | $0.12 | holding | — | — | — | May 15, 2013 | May 15, 2016 | Common Stock | 100,000 | 3,350,000 | I |
Explanation of responses
- F1The Series A Convertible Preferred Stock has no expiration date.
- F2Issued as a loan origination fee in connection with a loan by the Reporting Person to the Company.
- F3The Convertible Promissory Note ("Note") is convertible into either (i) that number of the Company's common stock equal to the outstanding principal amount plus all accrued and unpaid interest, divided by $0.001 (the "Conversion Shares"), or (ii) one (1) share of the Series A Convertible Preferred Stock for every one thousand (1,000) Conversion Shares.
- F4Issued upon conversion of $5,000 Convertible Promissory Note.