SEC Form 4 · accession 0001683168-18-003640
Paysign, Inc. · PAYS
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Brian Polan
Other
Period of report
Dec 5, 2018
Accepted (ET)
Dec 7, 2018 · 4:40 pm EST
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0001496443
Table I — non-derivative securities
| Security | Date | Code | Shares | Price | A/D | Owned after | D/I | Nature of ownership |
|---|---|---|---|---|---|---|---|---|
| Common StockF1 | Dec 5, 2018 | A | 200,000 | — | A | 256,390 | D |
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Stock GrantF3,F2 | — | Dec 5, 2018 | C | 200,000 | D | — | — | Common Stock | 200,000 | 300,000 | D |
Explanation of responses
- F1N/A
- F2N/A
- F3On November 11 2016, the company granted Brian Polan five hundred thousand shares of common stock with a value of $78,795. The stock grant vested in equal amounts over a five year period on the last day of each calendar quarter if Mr. Polan still employed by the company at that time. As of December 5, 2018, two hundred thousand shares have vested and have been issued. Three hundred thousand shares have not vested and have not been issued.