SEC Form 4 · accession 0001415889-16-007552
Medovex Corp. · MDVX
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Steve Gorlin
Director
Period of report
Dec 1, 2016
Accepted (ET)
Dec 6, 2016 · 4:21 pm EST
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0001591165
Table I — non-derivative securities
| Security | Date | Code | Shares | Price | A/D | Owned after | D/I | Nature of ownership |
|---|---|---|---|---|---|---|---|---|
| Common StockF1,F2 | Dec 1, 2016 | P | 257,143 | $1.75 | D | 704,360 | D | |
| Common StockF1,F3 | Dec 1, 2016 | P | 314,286 | $1.75 | A | 1,018,592 | D |
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| WarrantsF4 | $1.85 | Dec 1, 2016 | P | 112,500 | D | Nov 9, 2015 | Nov 9, 2018 | Common Stock | 112,500 | 387,500 | D |
Explanation of responses
- F1Includes 125,000 shares held by Mr. Gorlin's spouse, Deborah Gorlin. Mr. Gorlin disclaims beneficial ownership of Deborah Gorlin's shares.
- F2The 257,143 shares represent a portion of the total number of shares issued to Mr. Gorlin against the conversion of a $1,000,000 promissory note (the "Note").
- F3The 314,286 shares were issued against the conversion of the Note.
- F4Represents an assignment of 112,500 warrants to purchase shares of common stock issued to the Reporting Person in connection with the Note.