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