0001213900-18-009713.txt : 20180726 0001213900-18-009713.hdr.sgml : 20180726 20180726174447 ACCESSION NUMBER: 0001213900-18-009713 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20180726 FILED AS OF DATE: 20180726 DATE AS OF CHANGE: 20180726 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: En Fidecomiso de Mi Vida 11/23/2010 Trust CENTRAL INDEX KEY: 0001719033 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38323 FILM NUMBER: 18972661 BUSINESS ADDRESS: STREET 1: 11024 GAITHER FARM ROAD CITY: ELLICOTT CITY STATE: MD ZIP: 21042 BUSINESS PHONE: 434-422-9800 MAIL ADDRESS: STREET 1: 11024 GAITHER FARM ROAD CITY: ELLICOTT CITY STATE: MD ZIP: 21042 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Johnson Bankole A. CENTRAL INDEX KEY: 0001718158 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38323 FILM NUMBER: 18972663 MAIL ADDRESS: STREET 1: 1180 SEMINOLE TRAIL STREET 2: SUITE 495 CITY: CHARLOTTESVILLE STATE: VA ZIP: 22901 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: ADIAL PHARMACEUTICALS, INC. CENTRAL INDEX KEY: 0001513525 STANDARD INDUSTRIAL CLASSIFICATION: PHARMACEUTICAL PREPARATIONS [2834] IRS NUMBER: 800667150 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 1180 SEMINOLE TRAIL STREET 2: SUITE 495 CITY: CHARLOTTESVILLE STATE: VA ZIP: 22902 BUSINESS PHONE: 434-422-9800 MAIL ADDRESS: STREET 1: 1180 SEMINOLE TRAIL STREET 2: SUITE 495 CITY: CHARLOTTESVILLE STATE: VA ZIP: 22902 FORMER COMPANY: FORMER CONFORMED NAME: ADial Pharmaceuticals, L.L.C. DATE OF NAME CHANGE: 20170515 FORMER COMPANY: FORMER CONFORMED NAME: Adial Pharmaceuticals, L.L.C. DATE OF NAME CHANGE: 20110218 3 1 f3121417johnson_adial.xml OWNERSHIP DOCUMENT X0206 3 2018-07-26 0 0001513525 ADIAL PHARMACEUTICALS, INC. ADIL 0001718158 Johnson Bankole A. 1180 SEMINOLE TRAIL, SUITE 495 CHARLOTTESVILLE VA 22901 1 0 1 0 0001719033 En Fidecomiso de Mi Vida 11/23/2010 Trust 11024 GAITHER FARM ROAD ELLICOTT CITY MD 21042 0 0 1 0 Common Stock 102654 D Common Stock 850896 I En Fideicomiso De Mi Vida 11/23/2010 (Trust) Common Stock 93000 I En Fidecomiso de Todos Mis Suenos Grantor Retained Annuity Trust dated June 27, 2017 Common Stock 22320 I En Fideicomiso De Mis Suenos 11/23/2010 (Trust) Common Stock 7440 I De Mi Amor 11/23/2010 (Trust) Common Stock 4650 I Efunbowale Johnson Common Stock 1395 I Ade Johnson Common Stock 1395 I Lola Johnson Common Stock 930 I Lina Tiouririne Common Stock 930 I Aida Tiouririne Warrant 7.63 2017-10-10 2031-12-31 Common Stock 3275 D Stock Option 5.70 2018-01-01 2027-06-30 Common Stock 5580 D Convertible Note 0.44 Common Stock 153114 D Dr. Johnson is the trustee of each of these trusts. Dr. Johnson has a voting proxy on this person's behalf that entitles him to vote these shares. The option has an exercise price of $5.70 per share and vests as to 1/6th of the grant on January 1, 2018 with the remaining shares vesting 1/36th on the first day of each month over the remaining 30 months. 153,114 shares issued upon consummation of this offering upon automatic conversion of a convertible note in the principal amount of $52,000 at a conversion price of $0.44 per share. /s/ Bankole A. Johnson 2018-07-26 En Fideicomiso De Mi Vida 11/23/2010 (Trust) By: /s/ Bankole A. Johnson 2018-07-26