| 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) 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)
| 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) |
| 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 | ||||
| Series A Convertible Preferred Stock | (1) | (1) | Common Stock | 51,507,749(2) | (1) | D | |
| Series A Convertible Preferred Stock | (1) | (1) | Common Stock | 51,507,749(3) | (1) | I | By Spouse |
| Series A Convertible Preferred Stock | (1) | (1) | Common Stock | 45,419,533(4) | (1) | I(5) | By United System Capital LLC |
| 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 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 954,277 shares of Series A Convertible Preferred Stock owned by the Reporting Person. |
| 3. Based on 954,277 shares of Series A Convertible Preferred Stock owned by the Reporting Person's spouse. |
| 4. Based on 841,481 shares of Series A Convertible Preferred Stock owned by United System Capital LLC. |
| 5. The Reporting Person is the manager of United System Capital LLC, has voting control over shares owned by United System Capital LLC, and may be deemed to have indirect beneficial ownership of all or a portion of the securities owned directly by United System Capital LLC, but disclaims beneficial ownership of the reported securities except to the extent of his pecuniary interest therein. |
| /s/ Benjamin Tran | 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. | ||
