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