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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) | $ 0.25 | 08/12/2013 | M | $ 1,511,688 (1) | 10/01/2010(1) | 10/01/2014 | Common Stock | $ 1,511,688 | (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 | 08/14/2013 | |
**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) | Three notes in the aggregate principal amount of $761,688 were purchased by the Reporting Person on October 1, 2010 pursuant to a Note and Warrant Purchase Agreement, dated as of October 1, 2010, between the Company and the investors party thereto. These notes were exercisable as of October 1, 2010. An additional three notes in the aggregate principal amount of $750,000 were purchased by the Reporting Person pursuant to an Amended and Restated Note and Warrant Purchase Agreement, dated as of November 11, 2011, between the Company and the investors party thereto. This second set of notes was exercisable starting during the November through December period of 2011. On August 12, 2013, the Reporting Person converted $1,511,688 in aggregate principal amount of the six notes, with accrued interest thereon of $317,869, at a conversion price of $0.25 per share of common stock (reduced from the previous conversion price of $1.00). |