SEC Form 4
FORM 4 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934
or Section 30(h) of the Investment Company Act of 1940
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
1. Name and Address of Reporting Person*
SCHILLER LEONARD M

(Last) (First) (Middle)
1110 N LAKE SHORE DR. APT. 9 SOUTH

(Street)
CHICAGO IL 60611

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
Jerrick Media Holdings, Inc. [ 10/19/2017 ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director 10% Owner
Officer (give title below) Other (specify below)
3. Date of Earliest Transaction (Month/Day/Year)
10/19/2017
4. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security (Instr. 3) 2. Transaction Date (Month/Day/Year) 2A. Deemed Execution Date, if any (Month/Day/Year) 3. Transaction Code (Instr. 8) 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 7. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V Amount (A) or (D) Price
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 3) 2. Conversion or Exercise Price of Derivative Security 3. Transaction Date (Month/Day/Year) 3A. Deemed Execution Date, if any (Month/Day/Year) 4. Transaction Code (Instr. 8) 5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) 6. Date Exercisable and Expiration Date (Month/Day/Year) 7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4) 8. Price of Derivative Security (Instr. 5) 9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) 10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 11. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V (A) (D) Date Exercisable Expiration Date Title Amount or Number of Shares
Warrant to Purchase Common Stock $0.2 10/19/2017 A 447,037 10/19/2017 10/19/2022 Common Stock 447,307 (1) 1,214,807 I By Leonard M. Schiller Revocable Trust
15% Convertible Note convertible into Common Stock $0.2 10/19/2017 A 447,037 10/19/2017 10/19/2019 Common Stock 447,307 (1) 1,661,844 I By Leonard M. Schiller Revocable Trust
Explanation of Responses:
1. On October 19, 2017, Jerrick Media Holdings, Inc. (the "Company") entered into a Conversion Agreement (the "Agreement") with Mr. Leonard Schiller whereby various promissory notes issued by the Company in favor of Mr. Schiller, totaling $89,407.36 in unpaid principal and interest (the "Debt Obligation"), were extinguished in favor of the issuance of: (a) a new 15% Secured Convertible Promissory Note (the "New Note") in the same amount of as the Debt Obligation; and (b) warrants to purchase shares of the Company's common stock. The New Note has a maturity date of October 19, 2019 and is convertible into shares of the Company's common stock at $0.20 per share. In connection with the Conversion Agreement, the Company also issued Mr. Schiller warrants to purchase 447,037 shares of the Company's common stock at an exercise price of $0.20 per share.
/s/ Leonard Schiller 10/20/2017
** Signature of Reporting Person Date
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
* If the form is filed by more than one reporting person, see Instruction 4 (b)(v).
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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