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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 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 | ||||||||
| Convertible Notes (1) | $ 0.5 | 07/25/2010 | A | $ 500,000 | 07/25/2010 | 12/02/2010(2) | Common Stock | 1,000,000 | (3) | $ 500,000 | D | ||||
| Warrants to purchase shares | $ 0.5 | 07/25/2010 | A | 250,000 | 07/25/2010 | 07/24/2017 | Common Stock | 250,000 | (3) | 250,000 | D | ||||
| Reporting Owner Name / Address | Relationships | |||
| Director | 10% Owner | Officer | Other | |
| PAPPAJOHN JOHN C/O CNS RESPONSE, INC. 85 ENTERPRISE, SUITE 410 ALISO VIEJO, CA 92656 |
X | X | ||
| /s/ John Pappajohn | 07/27/2010 | |
| **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) | On June 3, 2010 and July 25, 2010, the Reporting Person acquired secured promissory notes in the aggregate principal amount of $500,000. As of June 25, 2010, the Reporting Person entered into an agreement with the Issuer, pursuant to which the Issuer granted the Reporting Person the right to convert such notes into shares of common stock at a conversion price of $0.50, subject to customary anti-dilution adjustments. |
| (2) | The Note is subject to earlier repayment upon the occurrence of certain events described therein. |
| (3) | As of July 25, 2010, the date that (1) the conversion feature of the notes and (2) the warrants were acquired, the most recent transaction price quoted for the Issuer's common stock was $0.50 per share. |