-----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, CJ6UhdxEhJ3bTp/UMlcB+d5IvR+OwLiQlD56MYTJgiLJzTIxLe/ztZTcHYZuzA0Z oGDkYtOTEJD+nlQYWz5YBg== 0000898432-04-000917.txt : 20041108 0000898432-04-000917.hdr.sgml : 20041108 20041108191610 ACCESSION NUMBER: 0000898432-04-000917 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20041104 FILED AS OF DATE: 20041108 DATE AS OF CHANGE: 20041108 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: SURGENOR TIMOTHY R CENTRAL INDEX KEY: 0001304823 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 000-50505 FILM NUMBER: 041127148 BUSINESS ADDRESS: BUSINESS PHONE: 508-549-9981 MAIL ADDRESS: STREET 1: 100 FOXBOROUGH BOULEVARD STREET 2: SUITE 240 CITY: FOXBOROUGH STATE: MA ZIP: 02035 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Cyberkinetics Neurotechnology Systems, Inc. CENTRAL INDEX KEY: 0001180253 STANDARD INDUSTRIAL CLASSIFICATION: SURGICAL & MEDICAL INSTRUMENTS & APPARATUS [3841] IRS NUMBER: 134287300 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: SUITE 240 STREET 2: 100 FOXBOROUGH BLVD. CITY: FOXBOROUGH STATE: MA ZIP: 02035 BUSINESS PHONE: 508-549-9981 MAIL ADDRESS: STREET 1: SUITE 240 STREET 2: 100 FOXBOROUGH BLVD. CITY: FOXBOROUGH STATE: MA ZIP: 02035 FORMER COMPANY: FORMER CONFORMED NAME: TRAFALGAR VENTURES INC DATE OF NAME CHANGE: 20020814 4 1 cyberkinetics-surgenor_4ex.xml X0202 4 2004-11-04 0 0001180253 Cyberkinetics Neurotechnology Systems, Inc. CYKN.OB 0001304823 SURGENOR TIMOTHY R 100 FOXBOROUGH BLVD., SUITE 240 FOXBOROUGH MA 02035 1 1 0 0 President and CEO Common Stock 2004-11-04 4 P 0 40000 3.00 A 40000 I By Trust Common Stock 500 D Common Stock Warrant (Right to Purchase) 6.00 2004-11-04 4 P 0 13200 0 A 2004-11-04 2009-11-04 Common Stock 13200 13200 I By Trust Stock Options .01 2004-01-01 2013-01-01 Common Stock 900000 900000 D Includes 40,000 shares held by the Madeline L. Gregory and Caleb Loring III, Trustees trust. Mr. Surgenor's children are the primary beneficiaries of this trust and Mr. Surgenor and his wife retain a pecuniary interest in the trust. Transaction previously reported on Form 4, dated 10/19/04. The warrants were issued in connection with a private financing. No value was attributed to the warrants in the financing, and none can be determined at this time. Includes warrants to purchase 13,200 shares held by the Madeline L. Gregory and Caleb Loring III, Trustees trust. Mr. Surgenor's children are the primary beneficiaries of this trust and Mr. Surgenor and his wife retain a pecuniary interest in the trust. Transaction previously reported on Form 3, dated 10/14/04. /s/ Timothy R. Surgenor 2004-11-08 -----END PRIVACY-ENHANCED MESSAGE-----