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*
(Street)
| 2. Date of Event Requiring Statement (Month/Day/Year) 07/21/2016 | 3. Issuer Name and Ticker or Trading Symbol Sensus Healthcare, Inc. [ SRTS ] | |||||||||||||
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
| 5. If Amendment, Date of Original Filed (Month/Day/Year) | ||||||||||||||
6. Individual or Joint/Group Filing (Check Applicable Line)
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Table I - Non-Derivative Securities Beneficially Owned | |||
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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) |
Common Stock | 12,013 | D |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
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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 | ||||
Common Stock Warrants | 02/01/2013 | 02/01/2018 | Common Stock | 26,614 | 4.55 | D | |
Unit Warrants(1) | 06/08/2017 | 06/08/2021 | Common Stock(1) | 23,715 | 6.75(2) | D | |
Unit Warrants(1) | 06/08/2017 | 06/08/2021 | Warrants(1) | 23,715 | 6.75(2) | D |
Explanation of Responses: |
1. In connection with its initial public offering, Sensus Healthcare, Inc. issued to the reporting person warrants to acquire 23,715 units, each consisting of (i) one share of common stock and (ii) one warrant to purchase one share of common stock at an exercise price of $6.75 per share. The warrants underlying the units are exercisable at any time, and from time to time, in whole or in part, during the four-year period commencing on June 8, 2017. The warrants to acquire each component of the units underlying the warrants are reported separately in accordance with instruction 5(c)(iv) of Form 3. |
2. Represents the warrant exercise price for the underlying units, each of which consists of (i) one share of common stock and (ii) one warrant to acquire one share of common stock at an exercise price of $6.75 per share. |
Remarks: |
/s/ Gustav L. Schmidt, attorney in fact | 08/01/2016 | |
** 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. |