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) 01/11/2022 | 3. Issuer Name and Ticker or Trading Symbol Hillstream BioPharma Inc. [ HILS ] | |||||||||||||
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 | 284,090 | D | |
Common stock | 972,222 | I | See footnote(1) |
Common stock | 75,757 | I | See footnote(2) |
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 | ||||
Options (right to purchase) | (3) | 08/30/2024 | Common stock | 37,878 | 0.0792 | D |
Explanation of Responses: |
1. The shares of common stock are owned by Highpoint Pharmaceuticals LLC. Sireesh Appajosyula is the Managing Member of Highpoint Pharmaceuticals LLC and in such capacity has the right to vote and dispose of the securities held by such entity. |
2. The shares of common stock are owned by Mercer Lake Group LLC. Sireesh Appajosyula is the is the Managing Member of Mercer Lake Group LLC and in such capacity has the right to vote and dispose of the securities held by such entity. |
3. The Registrant issued the Reporting Person the options on August 30, 2019. The options vested immediately upon grant and become exercisable upon (i) consummation of the Registrant's initial public offering of its securities or (ii) consummation of a reverse merger of the Registrant with and into a public company. |
Remarks: |
Exhibit List: Exhibit 24 - Power of Attorney |
/s/ Randy Milby as Attorney-In-Fact for Sireesh Appajosyula | 01/11/2022 | |
** 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. |