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 MyDx, Inc. [ MYDX ] | 5. Relationship of Reporting Person(s) to Issuer (Check all applicable)
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3. Date of Earliest Transaction (Month/Day/Year) 06/30/2017 | ||||||||||||||||||||||||||
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 | 05/07/2018 | 05/07/2018 | J(1) | 1,750,000,000 | A | (1) | 1,789,351,606 | I | See Footnote(2) |
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 | ||||||||
Preferred Stock (Series B Convertible) | $0.0001 | 06/30/2017 | 06/30/2017 | J | 100,000(3) | 12/23/2016 | (3) | Common Stock | 1,000,000,000 | $0.5 | 200,000 | I | YCIG, Inc. | ||
Preferred Stock (Series B Convertible) | $0.0001 | 05/07/2018 | 05/07/2018 | C | 175,000 | 12/23/2016 | (1) | Common Stock | 1,750,000,000 | (1) | 25,000 | I | YCIG, Inc. |
Explanation of Responses: |
1. On May 7, 2018, Mr. Yazbeck converted 175,000 shares of Series B Convertible Preferred Stock into shares of Common Stock via a cashless conversion of the stated value of $1.00 per Series B share divided by a conversion price of $0.0001 per share for an issuance of 1,750,000,000 shares of Common Stock. |
2. Beneficial ownership of Daniel R. Yazbeck, directly and indirectly, as of the date of the filing of this Form 4 consists of 10,000 shares held directly by Mr. Yazbeck, 9,132,500 shares held by seven trusts for which Mr. Yazbeck serves as trustee, and 1,780,000,000 shares held by Mr. Yazbeck and YCIG, Inc. (an entity over whose securities Mr. Yazbeck has sole voting and sole investment control). |
3. On June 30, 2017, Mr. Yazbeck sold 100,000 shares of Series B Preferred for gross proceeds of $50,000. |
/s/ Daniel Yazbeck | 05/08/2018 | |
** 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. |