| 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) 12/19/2016 | 3. Issuer Name and Ticker or Trading Symbol Fuse Medical, Inc. [ FZMD ] | |||||||||||||
| 4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
| 5. If Amendment, Date of Original Filed (Month/Day/Year) 12/29/2016 | ||||||||||||||
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 | 4,000,000 | I | By Reeg Medical Industries, Inc.(1) |
| 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 | ||||
| Amended and Restated Promissory Note | 01/16/2017 | (2) | Common Stock | 650,000(3) | 0.08 | I | By Reeg Medical Industries, Inc.(1) |
| Explanation of Responses: |
| 1. These securities are directly owned by Reeg Medical Industries, Inc. ("RMI"), a Texas corporation. Christopher C. Reeg is the sole shareholder, sole director, and sole officer of RMI. Accordingly, Christopher C. Reeg indirectly beneficially owns the reported securities. |
| 2. The Amended and Restated Promissory Note, dated October 19, 2016, made by the Issuer and payable to the order of RMI, in the principal amount of $50,000 ("Note") became payable upon demand on December 19, 2016, and will be convertible into shares of common stock of the Issuer on or after January 16, 2017. The Note does not provide for a stated expiration date. |
| 3. On or after January 16, 2017, RMI will have the right to convert all or any portion of the then unpaid principal and interest balance of the Note into shares of common stock of the Issuer at a conversion price of $0.08 per share. The number of shares reported in box 3 is based on the application of such conversion rate to the amount of principal and interest that will be outstanding on January 16, 2017, if the Note remains outstanding on such date. |
| Remarks: |
| /s/ Christopher C. Reeg | 01/26/2018 | |
| ** 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. | ||
