-----BEGIN PRIVACY-ENHANCED MESSAGE----- Proc-Type: 2001,MIC-CLEAR Originator-Name: webmaster@www.sec.gov Originator-Key-Asymmetric: MFgwCgYEVQgBAQICAf8DSgAwRwJAW2sNKK9AVtBzYZmr6aGjlWyK3XmZv3dTINen TWSM7vrzLADbmYQaionwg5sDW3P6oaM5D3tdezXMm7z1T+B+twIDAQAB MIC-Info: RSA-MD5,RSA, R0Nr+Cp59xoQEhHXUkHH/C42jaRFq/7dRqyG0aN5uKWwd12QAwx6/kPC/JUL1MXJ gwL3vlx8lHiV/Bp7gFG3UQ== 0001179110-08-013452.txt : 20080708 0001179110-08-013452.hdr.sgml : 20080708 20080708165926 ACCESSION NUMBER: 0001179110-08-013452 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20080617 FILED AS OF DATE: 20080708 DATE AS OF CHANGE: 20080708 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Assured Pharmacy, Inc. CENTRAL INDEX KEY: 0001100592 STANDARD INDUSTRIAL CLASSIFICATION: RETAIL-DRUG STORES AND PROPRIETARY STORES [5912] IRS NUMBER: 980233878 STATE OF INCORPORATION: NV FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 17935 SKY PARK CIRCLE STREET 2: SUITE F CITY: IRVINE STATE: CA ZIP: 92614 BUSINESS PHONE: 949-222-9971 MAIL ADDRESS: STREET 1: 17935 SKY PARK CIRCLE STREET 2: SUITE F CITY: IRVINE STATE: CA ZIP: 92614 FORMER COMPANY: FORMER CONFORMED NAME: ERXSYS INC DATE OF NAME CHANGE: 20030916 FORMER COMPANY: FORMER CONFORMED NAME: SURFORAMA COM INC DATE OF NAME CHANGE: 20001128 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Shah Ameet CENTRAL INDEX KEY: 0001428696 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 000-33165 FILM NUMBER: 08943290 BUSINESS ADDRESS: BUSINESS PHONE: (212) 288-9920 MAIL ADDRESS: STREET 1: 545 FIFTH AVENUE STREET 2: SUITE 1109 CITY: NEW YORK STATE: NY ZIP: 10017 4 1 edgar.xml FORM 4 - X0303 4 2008-06-17 0 0001100592 Assured Pharmacy, Inc. APHY 0001428696 Shah Ameet 545 FIFTH AVENUE SUITE 1109 NEW YORK NY 10017 1 0 0 0 Common Stock 2008-06-17 4 J 0 448083 0 A 3941814 I By managed accounts Common Stock 2008-07-03 4 J 0 2500000 0 A 2500000 I By Mosaic Financial Services Warrants to Purchase Common Stock .6 2008-07-03 4 J 0 512500 0 A 2006-04-12 2009-04-12 Common Stock 512500 512500 I By managed account Warrants to Purchase Common Stock .6 2008-07-03 4 J 0 375000 0 A 2005-10-18 2008-10-18 Common Stock 375000 375000 I By managed account Warrants to Purchase Common Stock .6 2008-07-03 4 J 0 625000 0 A 2006-04-12 2009-04-12 Common Stock 625000 625000 I By managed account Warrants to Purchase Common Stock .6 2008-07-03 4 J 0 112500 0 A 2006-06-08 2009-06-08 Common Stock 112500 112500 I By managed account Warrants to Purchase Common Stock .6 2008-07-03 4 J 0 666875 0 A 2007-11-17 2009-11-17 Common Stock 666875 666875 I By managed accounts Warrants to Purchase Common Stock .6 2008-07-03 4 J 0 625000 0 A 2007-11-23 2008-11-23 Common Stock 625000 625000 I By managed accounts Warrants to Purchase Common Stock .6 2008-07-03 4 J 0 312500 0 A 2007-12-07 2008-12-07 Common Stock 312500 312500 I By managed accounts Warrants to Purchase Common Stock .6 2008-07-03 4 J 0 250000 0 A 2007-12-13 2008-12-13 Common Stock 250000 250000 I By managed accounts Warrants to Purchase Common Stock .6 2008-07-03 4 J 0 62500 0 A 2008-01-29 2009-01-29 Common Stock 62500 62500 I By managed accounts Warrants to Purchase Common Stock .6 2008-07-03 4 J 0 250000 0 A 2008-02-11 2009-02-11 Common Stock 250000 250000 I By managed accounts Warrants to Purchase Common Stock .8 2008-07-03 4 J 0 666875 0 A 2007-11-17 2010-11-17 Common Stock 666875 666875 I By managed accounts Warrants to Purchase Common Stock .8 2008-07-03 4 J 0 625000 0 A 2007-11-23 2009-11-23 Common Stock 625000 625000 I By managed accounts Warrants to Purchase Common Stock .8 2008-07-03 4 J 0 312500 0 A 2007-12-07 2009-12-07 Common Stock 312500 312500 I By managed accounts Warrants to Purchase Common Stock .8 2008-07-03 4 J 0 250000 0 A 2007-12-13 2009-12-13 Common Stock 250000 250000 I By managed accounts Warrants to Purchase Common Stock .8 2008-07-03 4 J 0 62500 0 A 2008-01-29 2010-01-29 Common Stock 62500 62500 I By managed accounts Warrants to Purchase Common Stock .8 2008-07-03 4 J 0 250000 0 A 2008-02-11 2010-02-11 Common Stock 250000 250000 I By managed accounts Convertible Debentures .4 2008-07-03 4 J 0 1333750 0 A 2007-11-17 2008-05-31 Common Stock 1333750 1333750 I By managed account Convertible Debentures .4 2008-07-03 4 J 0 1250000 0 A 2007-11-23 2008-05-31 Common Stock 1250000 1250000 I By managed account Convertible Debentures .4 2008-07-03 4 J 0 625000 0 A 2007-12-07 2008-05-31 Common Stock 625000 625000 I By managed account Convertible Debentures .4 2008-07-03 4 J 0 500000 0 A 2007-12-13 2008-05-31 Common Stock 500000 500000 I By managed account Convertible Debentures .4 2008-07-03 4 J 0 125000 0 A 2008-01-29 2008-05-31 Common Stock 125000 125000 I By managed account Convertible Debentures .4 2008-07-03 4 J 0 500000 0 A 2008-02-11 2008-05-31 Common Stock 500000 500000 I By managed account Convertible Debentures .4 2008-06-26 4 A 0 375000 0 A 2008-06-26 2008-07-31 Common Stock 375000 375000 I By managed account Warrants to Purchase Common Stock .6 2008-06-26 4 A 0 187500 0 A 2008-06-26 2009-06-26 Common Stock 187500 187500 I By managed accounts Warrants to Purchase Common Stock .8 2008-06-26 4 A 0 187500 0 A 2008-06-26 2010-06-26 Common Stock 187500 187500 I By managed accounts Convertible Debentures 0.4 2008-07-03 4 A 0 1250000 0 A 2008-07-03 2008-07-31 Common Stock 1250000 1250000 I By managed account Warrants to Purchase Common Stock 0.6 2008-07-03 4 A 0 625000 0 A 2008-07-03 2009-07-03 Common Stock 625000 625000 I By managed accounts Warrants to Purchase Common Stock 0.8 2008-07-03 4 A 0 625000 0 A 2008-07-03 2010-07-03 Common Stock 625000 625000 I By managed accounts Ameet Shah is Managing Partner of Mosaic Capital Advisors, LLC ("MCA"). MCA is owned by Mr. Shah and another investor and is the investment advisor to several hedge funds and private equity funds, including certain funds to which GP is the general partner. MPE General Partner, LLC ("GP") is owned by Mr. Shah and another investor. GP is a general partner or investment manager in a number of partnerships and funds, including partnerships and funds which hold Issuer's securities and for which MCA is the investment advisor. Mosaic Financial Services, LLC ("MFS LLC") is wholly-owned by MCA. The reporting person disclaims beneficial ownership of these shares except to an extent of the reporting person's pecuniary interest in the shares. This Form 4 reflects the issuance of 448,083 shares on June 17, 2008 that were reported as "to be issued" in the reporting person's Form 3. No reportable transactions have occurred in connection with these holdings. The date, transaction code, acquisition code and price are included only because information is required to be entered into those columns to file this form. The listed expiration date is the scheduled maturity date of the Convertible Debenture as of July 3, 2008. The unpaid principal due under the Convertible Debenture may be converted into Issuer Common Stock prior to payment of such principal (whether before or after the scheduled maturity of the Convertible Debenture). These $0.60 warrants are issuable in the future upon conversion of the Convertible Debentures. The dates listed in the Date Exercisable and Expiration Date columns relate to the date of issuance of the underlying Convertible Debenture. The warrants are exercisable for a 1 year period from the date of their future issuance, which may vary from the date listed in the Date Exercisable and Expiration Date columns. These $0.80 warrants are issuable in the future upon conversion of the Convertible Debentures. The dates listed in the Date Exercisable and Expiration Date columns relate to the date of issuance of the underlying Convertible Debenture. The warrants are exercisable for a 2 year period from the date of their future issuance, which may vary from the date listed in the Date Exercisable and Expiration Date columns. /s/ Ameet Shah 2008-07-08 -----END PRIVACY-ENHANCED MESSAGE-----