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)
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2. Date of Event Requiring Statement
(Month/Day/Year) 06/04/2007 |
3. Issuer Name and Ticker or Trading Symbol
RESPONSE GENETICS INC [ RGDX ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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5. If Amendment, Date of Original Filed
(Month/Day/Year) |
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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 | 150,862 | D | |
Common Stock | 367,808 | I | See Footnote(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 | ||||
Series A Junior Convertible Preferred Stock | 06/08/2007(2) | 06/08/2007(2) | Common Stock | 404,966 | $0 | D | |
Series A Junior Convertible Preferred Stock | 06/08/2007(2) | 06/08/2007(2) | Common Stock | 987,220 | $0 | I | See Footnote(1) |
Convertible Notes | 06/08/2007(3) | 06/08/2007(3) | Common Stock | 23,759 | $7 | D | |
Convertible Notes | 06/08/2007(3) | 06/08/2007(3) | Common Stock | 57,922 | $7 | I | See Footnote(1) |
Explanation of Responses: |
1. These shares are owned directly by David Michael Smith, the reporting filer's son and a director and a significant shareholder of the Company. The reporting filer disclaims beneficial ownership of these shares, except to the extent of any beneficial interest therein. |
2. Upon the closing of the Issuer's initial public offering, which is expected to be June 8, 2007, all of the outstanding shares of Series A Junior Convertible Perferred Stock will automatically convert into shares of common stock on a 1-for-5.2 basis. |
3. Upon closing of the Issuer's initial public offering the principal amount of promissory notes to certain stockholders (plus accrued but unpaid interest) will convert into shares of common stock at a fixed conversion price equal to the intial public offering price per share. |
/s/ Marianne Staniunas, Attorney-in-fact | 06/04/2007 | |
** 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. |