X0306
4
2017-10-03
0
0001138476
PACIFIC HEALTH CARE ORGANIZATION INC
PFHO
0001271519
KUBOTA TOM
2618 SAN MIGUEL DRIVE, #477
NEWPORT BEACH
CA
92660
1
1
1
0
CEO & President
Common
2017-10-03
4
P
0
100
15.00
A
484100
D
Common
2017-10-03
4
P
0
1400
14.20
A
485500
D
Series A Preferred
0
Common Stock
1000
1000
D
Employee Stock Options
15
Common Stock
45750
45750
D
Employee Stock Options
15
Common Stock
4250
50000
D
The Reporting Person holds the shares through the Tom Kubota Revocable Trust of 2013 (the "Trust"). The Reporting Person is the sole Trustee of the Trust. As such, the Reporting Person may be deemed to have voting and/or investment power over the shares held by the Trust and therefore may be deemed to be the beneficial owner of those shares.
The Series A Preferred Stock converts into Common Stock of the Issuer on a 1:1 basis at any time at the election of the Reporting Person and has no expiration date.
The options vest on August 7, 2018. Vesting is subject to the Reporting Person remaining continuously employed with the Company from the date of grant, August 7, 2017 to August 7, 2018, except in the event the Reporting Person's employment terminates as a result of death or disability, in which case, the options shall vest to the designated beneficiary of the Reporting Person on the one-year anniversary of the Transaction Date. Vested options become exercisable on August 7, 2018 and expire on August 7, 2022.
/s/ Tom Kubota
2017-10-03