0001213900-21-014887.txt : 20210311 0001213900-21-014887.hdr.sgml : 20210311 20210311170543 ACCESSION NUMBER: 0001213900-21-014887 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20210309 FILED AS OF DATE: 20210311 DATE AS OF CHANGE: 20210311 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Carter Charles Ross CENTRAL INDEX KEY: 0001779359 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 000-55195 FILM NUMBER: 21734106 MAIL ADDRESS: STREET 1: C/O GI DYNAMICS, INC. STREET 2: 745 ATLANTIC AVENUE CITY: BOSTON STATE: MA ZIP: 02111 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: GI DYNAMICS, INC. CENTRAL INDEX KEY: 0001245791 STANDARD INDUSTRIAL CLASSIFICATION: SURGICAL & MEDICAL INSTRUMENTS & APPARATUS [3841] IRS NUMBER: 000000000 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 320 CONGRESS STREET STREET 2: 3RD FLOOR CITY: BOSTON STATE: MA ZIP: 02210 BUSINESS PHONE: 781-357-3310 MAIL ADDRESS: STREET 1: 320 CONGRESS STREET STREET 2: 3RD FLOOR CITY: BOSTON STATE: MA ZIP: 02210 FORMER COMPANY: FORMER CONFORMED NAME: GI DYNAMICS INC DATE OF NAME CHANGE: 20030623 4 1 ownership.xml X0306 4 2021-03-09 0 0001245791 GI DYNAMICS, INC. NONE 0001779359 Carter Charles Ross 320 CONGRESS STREET, FLOOR 3 BOSTON MA 02210 0 1 0 0 CFO and Secretary Stock Option (right to buy) 1.1204 2021-03-09 4 D 0 385226 0.00 D 2029-09-19 Common Stock 385226 0 D The option provided for vesting over a four (4) year period, with one quarter (1/4) of the shares subject to the Option vesting on the one (1) year anniversary of the transaction date, and the remaining shares vesting on a quarterly basis over the following three (3) years of continuous service. The option was canceled by mutual agreement of the reporting person and the issuer pursuant to the terms and conditions of a stock option cancellation agreement entered into on March 9, 2021, which cancellation is to be deemed effective as of December 31, 2020. /s/ Charles R. Carter 2021-03-11