0001185185-23-000650.txt : 20230621 0001185185-23-000650.hdr.sgml : 20230621 20230621162128 ACCESSION NUMBER: 0001185185-23-000650 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20230620 FILED AS OF DATE: 20230621 DATE AS OF CHANGE: 20230621 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: 231030144 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 X0407 4 2023-06-20 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 0 Common 2023-06-20 4 P 0 2000 0.90 A 8090000 D Common 2023-06-20 4 P 0 35000 0.87 A 8125000 D Series A Preferred 0 Common Stock 16000 16000 D 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 2023-06-21