0001213900-18-010083.txt : 20180802 0001213900-18-010083.hdr.sgml : 20180802 20180802160309 ACCESSION NUMBER: 0001213900-18-010083 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20180731 FILED AS OF DATE: 20180802 DATE AS OF CHANGE: 20180802 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Gilliland Robertson H. CENTRAL INDEX KEY: 0001718351 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38323 FILM NUMBER: 18988198 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 4 1 ownership.xml OWNERSHIP DOCUMENT X0306 4 2018-07-31 0 0001513525 ADIAL PHARMACEUTICALS, INC. ADIL 0001718351 Gilliland Robertson H. 1180 SEMINOLE TRAIL, SUITE 495 CHARLOTTESVILLE, VA 22901 1 0 0 0 Common Stock 2018-07-31 4 C 0 29931 A 95424 I Owned by Keller Enterprises, LLC Common Stock 2018-07-31 4 P 0 14000 A 109424 I Owned by Keller Enterprises, LLC Convertible Note 0.44 2018-07-31 4 C 0 29931 D Common Stock 29931 0 I Owned by Keller Enterprises, LLC Warrant to purchase common stock 6.25 2018-07-31 4 C 0 29931 A 2018-07-31 2023-07-31 Common Stock 29931 29931 I Owned by Keller Enterprises, LLC Warrant to purchase common stock 6.25 2018-07-31 4 P 0 14000 A 2018-07-31 2023-07-31 Common Stock 43931 43931 I Owned by Keller Enterprises, LLC The 29,931 shares of common stock and a warrant to purchase 29,931 shares of common stock were issued upon automatic conversion of a convertible note in the principal amount of $10,000 at a conversion price of $0.44 per share upon consummation of the initial public offering of the issuer on July 31, 2018. Mr. Gilliland is the principal of Keller Enterprises, LLC ("Keller"). On July 31, 2018, Keller purchased 14,000 units (the "Units") in the initial public offering of the issuer at a price of $5.00 per Unit, which corresponds to a price of $4.99 per share of common stock and $0.01 per warrant. Each Unit consisted of one share of common stock and a warrant to purchase one share of common stock. The shares of common stock and warrants were immediately separable upon issuance of the Units in the IPO. /s/ Robertson H. Gilliland 2018-07-31