SEC Form 4
| FORM 4 | UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP 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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| Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). | |||||||||||||||||
1. Name and Address of Reporting Person*
(Street)
| 2. Issuer Name and Ticker or Trading Symbol Medovex Corp. [ MDVX ] | 5. Relationship of Reporting Person(s) to Issuer (Check all applicable)
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| 3. Date of Earliest Transaction (Month/Day/Year) 02/09/2017 | ||||||||||||||||||||||||||
| 4. 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 Acquired, Disposed of, or Beneficially Owned | ||||||||||
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| 1. Title of Security (Instr. 3) | 2. Transaction Date (Month/Day/Year) | 2A. Deemed Execution Date, if any (Month/Day/Year) | 3. Transaction Code (Instr. 8) | 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) | 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) | 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 7. Nature of Indirect Beneficial Ownership (Instr. 4) | |||
| Code | V | Amount | (A) or (D) | Price | ||||||
| Common Stock | 02/09/2017 | P | 67,307(1) | A | $1.04 | 617,172(2)(3)(4) | D | |||
| Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||||||||||
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| 1. Title of Derivative Security (Instr. 3) | 2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) | 6. Date Exercisable and Expiration Date (Month/Day/Year) | 7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4) | 8. Price of Derivative Security (Instr. 5) | 9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) | 10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 11. Nature of Indirect Beneficial Ownership (Instr. 4) | ||||
| Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||||||
| Warrant to purchase shares of Common Stock | $1.5 | 02/09/2017 | P | 33,654(5) | 02/09/2017 | 02/09/2022 | Common Stock | 33,654(5) | $1.04 | 95,968(6)(7) | D | ||||
| Explanation of Responses: |
| 1. The shares were purchased as part of a private placement unit offering for $1.04 per unit, each unit consisting of one share of common stock and one-half of a warrant to purchase one share of common stock at an exercise price per share equal to $1.50 per share for a period of five (5) years. |
| 2. Includes 487,337 shares held by The Jarrett S. & Rebecca L. Gorlin Family Limited Partnership. Mr. Gorlin disclaims beneficial ownership of these shares. |
| 3. Includes 9,615 shares held by JARRETT GORLIN C/F LOGAN GORLIN UTMA/GA. The Reporting Person claims beneficial ownership of these shares. |
| 4. Includes 9,615 shares held by JARRETT GORLIN C/F TAYLOR GORLIN UTMA/GA. The Reporting Person claims beneficial ownership of these shares. |
| 5. The warrants were purchased as part of a private placement unit offering for $1.04 per unit, each unit consisting of one share of common stock and one-half of a warrant to purchase one share of common stock at an exercise price per share equal to $1.50 per share for a period of five (5) years. |
| 6. Includes 4,808 warrants to purchase shares of common stock held by JARRETT GORLIN C/F LOGAN GORLIN UTMA/GA. The Reporting Person claims beneficial ownership of these shares. |
| 7. Includes 4,808 warrants to purchase shares of common stock held by JARRETT GORLIN C/F TAYLOR GORLIN UTMA/GA. The Reporting Person claims beneficial ownership of these shares. |
| /s/ Jarrett Gorlin | 02/14/2017 | |
| ** 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 4 (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. | ||