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 |
|
1. Name and Address of Reporting Person*
(Street)
|
2. Date of Event Requiring Statement
(Month/Day/Year) 06/19/2007 |
3. Issuer Name and Ticker or Trading Symbol
Modigene Inc. [ MODG.OB ] |
|||||||||||||
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
|
5. If Amendment, Date of Original Filed
(Month/Day/Year) |
||||||||||||||
6. Individual or Joint/Group Filing (Check Applicable Line)
|
Table I - Non-Derivative Securities Beneficially Owned | |||
---|---|---|---|
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, par value $0.00001 per share | 1,023,871(1) | I | By Spencer Trask Breakthrough Partners LLC(1) |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
---|---|---|---|---|---|---|---|
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 | ||||
Stock option (right to buy) | (2) | 09/25/2016 | Common Stock | 85,323 | $0.88 | D | |
Stock option (right to buy) | 05/09/2008 | 05/09/2017 | Common Stock | 25,000 | $2 | D | |
Warrant (right to buy) | 05/09/2007 | 12/14/2015 | Common Stock | 298,403 | $0.88 | D | |
Warrant (right to buy) | 05/09/2007 | 05/09/2012 | Common Stock | 143,147 | $2.5 | D |
Explanation of Responses: |
1. Held in the name of Spencer Trask Breakthrough Partners LLC ("Breakthrough"), as to which Mr. Stern shares voting and investment power. Mr. Stern disclaims beneficial ownership of the securities except to the extent of his pecuniary interest therein. Breakthrough. acquired the 1,023,871 shares of issuer common stock in exchange for 600,000 shares of common stock of Modigene Inc., a Delaware corporation ("Modigene Delaware"), pursuant to Modigene Delaware's merger with a wholly-owned subsidiary of the issuer on May 9, 2007 (the "Merger"). Of the 1,023,871 shares issued to Breakthrough in the Merger, 51,194 shares are currently being held in escrow and are subject to forfeiture during the two-year period following the Merger to satisfy claims arising as a result of Modigene Delaware's breach of its representations, warranties or covenants in the merger agreement. |
2. Received in connection with the Merger in exchange for a director stock option to acquire 50,000 shares of Modigene Delaware common stock at $1.50 per share. Option was fully vested at the time of the Merger. |
/s/ Adam Stern | 06/19/2007 | |
** 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. |