Robert J Brilon Form 3 Spine Injury Solutions / ROBERT J BRILON ownership change

SEC Form 3

FORM 3

UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES

Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934
or Section 30(h) of the Investment Company Act of 1940

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1. Name and Address of Reporting Person^*

BRILON ROBERT J

(Last) (First) (Middle)

C/O SPINE INJURY SOLUTIONS, INC.

600 ANTON BOULEVARD, SUITE 1100

(Street)

COSTA MESA CA 92626

(City) (State) (Zip)

2. Date of Event Requiring Statement (Month/Day/Year)
03/31/2022

3. Issuer Name and Ticker or Trading Symbol
Spine Injury Solutions, Inc [ SPIN ]

4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)

	Director	10% Owner
X	Officer (give title below)	Other (specify below)
Chief Financial Officer

5. If Amendment, Date of Original Filed (Month/Day/Year)

6. Individual or Joint/Group Filing (Check Applicable Line)

X	Form filed by One Reporting Person
	Form filed by More than One Reporting Person

Table I - Non-Derivative Securities Beneficially Owned
1. Title of Security (Instr. 4)	2. Amount of Securities Beneficially Owned (Instr. 4)	3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5)	4. Nature of Indirect Beneficial Ownership (Instr. 5)

Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 4)	2. Date Exercisable and Expiration Date (Month/Day/Year)		3. Title and Amount of Securities Underlying Derivative Security (Instr. 4)		4. Conversion or Exercise Price of Derivative Security	5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5)	6. Nature of Indirect Beneficial Ownership (Instr. 5)
	Date Exercisable	Expiration Date	Title	Amount or Number of Shares
Series A Convertible Preferred Stock	(1)	(1)	Common Stock	1,287,694(2)	(1)	D

Explanation of Responses:

1. Each share of Series A Convertible Preferred Stock has no expiration date and is automatically convertible into 53.97561 shares of Issuer's common stock upon obtaining shareholder and regulatory approvals and the Issuer's filing a certificate of amendment to the certificate of incorporation authorizing a sufficient number of shares of common stock to permit a full conversion of all issued and outstanding Series A Preferred Stock. Each share of Series A Convertible Preferred Stock is entitled to receive dividends and vote on an "as converted" basis with the common stock.

2. Based on 28,857 shares of Series A Convertible Preferred Stock owned by the Reporting Person.

	/s/ Robert J. Brilon	04/06/2022
	** Signature of Reporting Person	Date
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
* If the form is filed by more than one reporting person, see Instruction 5 (b)(v).
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure.
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number.