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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 Note (1) | $ 0.0472 | 01/25/2013 | M | $ 200,000 (1) | 11/28/2012 | 11/28/2013 | Common Stock | 4,300,551 | (1) | $ 300,000 (2) | D | ||||
Convertible Note (1) | $ 0.0472 | 03/21/2013 | M | $ 300,000 (1) | 11/28/2012 | 11/28/2013 | Common Stock | 6,538,258 | (1) | 0 | 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 | 06/06/2013 | |
**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) | These Notes were acquired by the Reporting Person as reported on the Reporting Person's Form 4 filed with the Securities & Exchange Commission on December 13, 2012. On January 25, 2013, the Reporting Person converted $200,000 in aggregate principal amount of such Notes and $2,900 in accrued interest. On March 21, 2013, the Reporting Person converted $300,000 in aggregate principal amount of such Notes and $8,475 in accrued interest. The conversion price was $0.04718, which has been rounded to $0.0472 in the above table. |
(2) | Does not include accrued interest. |