SEC Form 3
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
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1. Name and Address of Reporting Person*
Chudnovsky Yekaterina

(Last) (First) (Middle)
C/O IMMIX BIOPHARMA, INC.
11400 WEST OLYMPIC BLVD., SUITE 200

(Street)
LOS ANGELES CA 90064

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
08/22/2023
3. Issuer Name and Ticker or Trading Symbol
Immix Biopharma, Inc. [ IMMX ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director X 10% Owner
Officer (give title below) Other (specify below)
5. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
Form filed by More than One Reporting Person
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 3,241,076 I Held by GKCC, 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
Pre-Funded Common Stock Purchase Warrant (2) (2) Common Stock 1,913,661 $0.0001 I Held by GKCC, LLC(1)
Explanation of Responses:
1. Yekaterina (Katie) Chudnovsky is the sole member and manager of GKCC, LLC and may be deemed to beneficially own the shares held by GKCC, LLC.
2. The Pre-Funded Warrants are immediately exercisable by GKCC, LLC at an exercise price of $0.0001 per Pre-Funded Warrant share, subject to the terms and provisions set forth in that certain Pre-Funded Warrant to Purchase Common Stock, dated August 22, 2023. The Pre-Funded Warrants have no expiration date.
Remarks:
/s/ Yekaterina Chudnovsky 08/23/2023
** 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.
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