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) 05/12/2022 | 3. Issuer Name and Ticker or Trading Symbol ACTELIS NETWORKS INC [ ASNS ] | |||||||||||||
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 | ||||
Option | (1) | 06/30/2025 | Common Stock | 3,895 | 0.0644 | D | |
Option | (2) | 11/04/2025 | Common Stock | 3,895 | 0.0644 | D | |
Option | (3) | 01/21/2026 | Common Stock | 779 | 0.0644 | D | |
Option | (4) | 06/21/2026 | Common Stock | 8,569 | 0.0644 | D | |
Option | (5) | 06/08/2027 | Common Stock | 10,870 | 0.1058 | D | |
Option | (6) | 03/06/2029 | Common Stock | 10,870 | 0.1058 | D |
Explanation of Responses: |
1. This Option grant was vested in full on 06/29/2019. |
2. This Option grant was vested in full on 11/03/2019. |
3. This Option grant was vested in full on 01/20/2020. |
4. This Option grant was vested in full on 06/20/2020. |
5. This Option grant was vested in full on 06/07/2021. |
6. This Option grant is approximately 83% vested as of May 12, 2022, with the remaining 17% of the Option grant vesting at a rate of 226 options per month until December 29, 2022 at which point the Option grant shall be fully vested, subject to Mr. Winkler-Solomon remaining continuously employed through the final vesting date. |
/s/ Michal Winkler-Solomon | 05/17/2022 | |
** 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. |