| 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) 01/01/2022 | 3. Issuer Name and Ticker or Trading Symbol Mind Medicine (MindMed) Inc. [ MNMD ] | |||||||||||||
| 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) |
| Subordinate Voting Shares | 675,000(1) | 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 | ||||
| Stock Option (Right to Buy) | (2) | 08/13/2024 | Subordinate Voting Shares | 2,250,000 | 0.34(3) | D | |
| Stock Option (Right to Buy) | (4) | 02/27/2025 | Subordinate Voting Shares | 750,000 | 0.26(5) | D | |
| Stock Option (Right to Buy) | (6) | 04/16/2026 | Subordinate Voting Shares | 682,500 | 2.42(7) | D | |
| Explanation of Responses: |
| 1. 525,000 of these shares are represented by restricted stock units ("RSUs"). Each RSU represents a contingent right to receive one Subordinate Voting Share of the Issuer. The RSUs shall vest as to 25% on February 27, 2021 and the remainder shall vest in 36 equal monthly installments beginning on March 27, 2021, subject to the Reporting Person providing continuous service to the Issuer on each such foregoing date. |
| 2. 25% of the shares underlying the option vested and became exercisable on August 13, 2021; the remaining shares underlying the option vest and become exercisable in 36 equal monthly installments beginning on September 13, 2021, subject to the Reporting Person providing continuous service to the Issuer on each such date. |
| 3. The option grant has an exercise price of $0.43 Canadian Dollars. This represents the exercise price in United States Dollars. |
| 4. The shares underlying the option vest and become exercisable in 36 equal monthly installments beginning on March 27, 2021, subject to the Reporting Person providing continuous service to the Issuer on each such date. |
| 5. The option grant has an exercise price of $0.33 Canadian Dollars. This represents the exercise price in United States Dollars. |
| 6. 25% of the shares underlying the option shall vest and become exercisable on July 15, 2022; the remaining shares underlying the option shall vest and become exercisable in 36 equal monthly installments beginning on August 15, 2022, subject to the Reporting Person providing continuous service to the Issuer on each such date. |
| 7. The option grant has an exercise price of $3.08 Canadian Dollars. This represents the exercise price in United States Dollars. |
| Remarks: |
| Exhibit List - Exhibit 24 - Power of Attorney |
| /s/ Robert Barrow, Attorney-in-Fact | 01/13/2022 | |
| ** 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. | ||
