0001185185-21-000453.txt : 20210402
0001185185-21-000453.hdr.sgml : 20210402
20210402161631
ACCESSION NUMBER: 0001185185-21-000453
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20210401
FILED AS OF DATE: 20210402
DATE AS OF CHANGE: 20210402
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: KUBOTA TOM
CENTRAL INDEX KEY: 0001271519
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 000-50009
FILM NUMBER: 21802151
MAIL ADDRESS:
STREET 1: 615 BAY HILL DR
CITY: NEWPROT BEACH
STATE: CA
ZIP: 92660
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: PACIFIC HEALTH CARE ORGANIZATION INC
CENTRAL INDEX KEY: 0001138476
STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-MISC HEALTH & ALLIED SERVICES, NEC [8090]
IRS NUMBER: 870285238
STATE OF INCORPORATION: UT
FISCAL YEAR END: 1231
BUSINESS ADDRESS:
STREET 1: 1201 DOVE STREET
STREET 2: SUITE 300
CITY: NEWPORT BEACH
STATE: CA
ZIP: 92260
BUSINESS PHONE: (949) 721-8272
MAIL ADDRESS:
STREET 1: 1201 DOVE STREET
STREET 2: SUITE 300
CITY: NEWPORT BEACH
STATE: CA
ZIP: 92260
4
1
ownership.xml
X0306
4
2021-04-01
0
0001138476
PACIFIC HEALTH CARE ORGANIZATION INC
PFHO
0001271519
KUBOTA TOM
2618 SAN MIGUEL DRIVE, #477
NEWPORT BEACH
CA
92660
1
1
1
0
CEO & President
Common
2021-04-01
4
P
0
1000
1.15
A
7894000
D
Common
2021-04-01
4
P
0
1000
1.13
A
7895000
D
Series A Preferred
0
Common Stock
16000
16000
D
The transaction was executed in multiple trades all at $1.15 per share. The reporting person hereby undertakes to provide upon request to the SEC staff, Pacific Health Care Organization, Inc. or a shareholder of Pacific Health Care Organization, Inc., full information regarding the number of shares acquired in each trade.
The Reporting Person holds the shares through the Tom Kubota Revocable Trust of 2013 (the "Trust"). The Reporting Person is the sole Trustee of the Trust. As such, the Reporting Person may be deemed to have voting and/or investment power over the shares held by the Trust and therefore may be deemed to be the beneficial owner of those shares.
The Series A Preferred Stock converts into Common Stock of the Issuer on a 1:1 basis at any time at the election of the Reporting Person and has no expiration date.
/s/ Tom Kubota
2021-04-02