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