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)
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2. Date of Event Requiring Statement
(Month/Day/Year) 10/04/2023 |
3. Issuer Name and Ticker or Trading Symbol
La Rosa Holdings Corp. [ LRHC ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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5. If Amendment, Date of Original Filed
(Month/Day/Year) 10/04/2023 |
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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 | 5,400,000 | D | |
Series X Super Voting Preferred Stock | 2,000(2) | 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 | ||||
Series A Convertible Preferred Stock | 10/12/2023 | 10/12/2023 | Common Stock | 377,428 | (1) | D | |
Series A Convertible Preferred Stock | 10/12/2023 | 10/12/2023 | Common Stock | 285 | (4) | I | By Celebration Condos Office, LLC |
Warrant to Purchase Common Stock | 12/02/2022 | 12/02/2027 | Common Stock | 50,000 | 5(3) | D |
Explanation of Responses: |
1. As of October 4, 2023, Mr. La Rosa owned 1,321 shares of Series A Convertible Preferred Stock, $0.0001 par value per share, which automatically converted into 377,428 shares of the Company's common stock based on a 30% discount to the per share price on the date of closing of the Company's initial public offering made pursuant to its registration statement, as amended (File No. 333-264372), as filed with the Securities and Exchange Commission. This amendment is being filed to move these shares of Series A Preferred Stock from Table II to Table I of the Form 3 filed on October 4, 2023. |
2. The Series X Super Voting Preferred Stock that has 10,000 votes per share and votes together as a class with the Company's common stock. |
3. Pursuant to the terms of the warrant, the "Exercise Price" is the lower of: (i) $5.00 per share of common stock, or (ii) the price per share of any offering by the Company subsequent to the Company's initial public offering made pursuant to its registration statement, as amended (File No. 333-264372), as filed with the Securities and Exchange Commission, subject to adjustment as provided in the warrant. |
4. As of October 4, 2023, Celebration Condos Office, LLC, a limited liability company, owned and controlled by Joseph La Rosa, owned 1 share of Series A Convertible Preferred Stock, $0.0001 par value per share. This amendment is being filed to include this share of Series A Preferred Stock beneficially held indirectly by Joseph La Rosa which was inadvertently omitted from Mr. La Rosa's Form 3 filed on October 4, 2023. |
/s/ Joseph La Rosa | 10/16/2023 | |
** 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. |