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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | |||
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 control number. | SEC 1474 (9-02) |
1. Title of Derivative Security (Instr. 3) |
2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) |
5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4, and 5) |
6. Date Exercisable and Expiration Date (Month/Day/Year) |
7. Title and Amount of Underlying Securities (Instr. 3 and 4) |
8. Price of Derivative Security (Instr. 5) |
9. Number of Derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) |
10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
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Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||||||
5% Convertible Promissory Note | $ 1 | 10/20/2010 | P | 150,000 | 10/21/2010 | 12/31/2010 | Common Stock | 150,000 | $ 0 | 3,066,666 | D | ||||
Warrant (2) | $ 1 | 10/20/2010 | P | 150,000 | 01/01/2011 | 10/20/2013 | Common Stock | 150,000 | $ 1 | 3,216,666 | D | ||||
5% Convertible Promissory Note | $ 1 | 11/04/2010 | P | 250,000 | 11/05/2010 | 12/31/2010 | Common Stock | 250,000 | $ 0 | 3,466,666 | D | ||||
Warrant (2) | $ 1 | 11/04/2010 | P | 250,000 | 01/01/2011 | 11/04/2013 | Common Stock | 250,000 | $ 1 | 3,716,666 | D | ||||
Warrant (3) | $ 1.5 | 01/01/2011 | 11/15/2015 | Common Stock | 300,000 | 4,016,666 | D | ||||||||
Warrant | $ 0.6 | 12/31/2010 | G | 280,000 | 12/21/2009 | 09/22/2012 | Common Stock | 280,000 | $ 0.6 | 3,736,666 | D |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
PETIT PARKER H C/O MIMEDX GROUP, INC. 811 LIVINGSTON COURT, SUITE B MARIETTA, GA 30067 |
X | Chief Executive Officer |
/s/ Michael J. Senken, by Power of Attorney | 01/04/2011 | |
**Signature of Reporting Person | Date |
* | If the form is filed by more than one reporting person, see Instruction 4(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). |
(1) | Number of shares held directly by Mr. Petit. Mr. Petit also beneficially owns 150,000 shares held by the Parker H. Petit Grantor Trust, of which he serves as the Trustee; 150,000 shares held by Petit Investments LP of which he serves as General Partner and Limited Partner and possesses shared voting and investment control; and 975,000 shares held by Cox Road Partners II LLP, 975,000 shares held by Cox Road Partners LLLP, and 975,000 shares held by Petit Investments LLLP II, limited liability limited partnerships over which Mr. Petit possesses sole voting and investment control. |
(2) | In conjunction with the 5% Convertible Promissory Note, the holder was issued warrants to purchase common stock. |
(3) | In conjunction with the purchase of common stock listed in table 1 above, the holder was issued warrants to purchase common stock. |