FORM 3 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES 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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1. Name and Address of Reporting Person*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 06/14/2022 |
3. Issuer Name and Ticker or Trading Symbol
Heart Test Laboratories, Inc. [ HSCS ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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5. If Amendment, Date of Original Filed
(Month/Day/Year) |
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6. Individual or Joint/Group Filing (Check Applicable Line)
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Table I - Non-Derivative Securities Beneficially Owned | |||
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1. Title of Security (Instr. 4) | 2. Amount of Securities Beneficially Owned (Instr. 4) | 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 4. Nature of Indirect Beneficial Ownership (Instr. 5) |
Common Stock | 441,522 | D | |
Common Stock | 4,040 | I | By Daughter |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
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1. Title of Derivative Security (Instr. 4) | 2. Date Exercisable and Expiration Date (Month/Day/Year) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 6. Nature of Indirect Beneficial Ownership (Instr. 5) | ||
Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Warrants | 11/17/2021 | 10/12/2026 | Common Stock | 30 | $2.89 | D | |
Warrants | 06/28/2013 | 06/28/2023 | Common Stock | 379 | $3.47 | D | |
Warrants | 08/23/2013 | 08/23/2023 | Common Stock | 644 | $3.47 | D | |
Series C Convertible Preferred Stock | (1) | (1) | Common Stock | 7,894 | $6.59 | D | |
Employee Stock Option (Right to Buy) | (2) | 05/01/2026 | Common Stock | 18,939 | $12.21 | D | |
Employee Stock Option (Right to Buy) | (3) | 05/01/2026 | Common Stock | 3,788 | $12.21 | D | |
Employee Stock Option (Right to Buy) | (4) | 03/14/2028 | Common Stock | 7,576 | $15.18 | D | |
Employee Stock Option (Right to Buy) | (5) | 03/14/2028 | Common Stock | 7,576 | $15.18 | D | |
Employee Stock Option (Right to Buy) | (6) | 03/14/2028 | Common Stock | 7,576 | $15.18 | D | |
Employee Stock Option (Right to Buy) | (7) | 11/01/2028 | Common Stock | 7,576 | $15.18 | D | |
Employee Stock Option (Right to Buy) | (8) | 11/01/2028 | Common Stock | 7,576 | $15.18 | D | |
Employee Stock Option (Right to Buy) | (9) | 11/01/2028 | Common Stock | 7,576 | $15.18 | D | |
Employee Stock Option (Right to Buy) | (10) | 09/01/2029 | Common Stock | 22,727 | $1.29 | D | |
Employee Stock Option (Right to Buy) | (11) | 09/01/2029 | Common Stock | 30,303 | $1.29 | D | |
Employee Stock Option (Right to Buy) | (12) | 11/06/2030 | Common Stock | 26,515 | $1.29 | D | |
Employee Stock Option (Right to Buy) | (13) | 11/06/2030 | Common Stock | 26,515 | $1.29 | D | |
Employee Stock Option (Right to Buy) | (14) | 03/01/2032 | Common Stock | 26,515 | $3.47 | D | |
Employee Stock Option (Right to Buy) | (15) | 03/01/2032 | Common Stock | 26,515 | $3.47 | D |
Explanation of Responses: |
1. The Convertible Preferred Stock may be converted at any time, at the Holder's election and there is no expiration. The conversion ratio is 3.7954 shares of Common Stock for each share of Series C Preferred Stock. |
2. The entire option has become fully-vested and may be exercised at any time at the Holder's election. |
3. The option becomes fully-vested and may be exercised at any time at Holder's election upon the achievement of performance-based criteria related to approval by the U.S. Food and Drug Administration of certain of the Company's products. As of the date of this filing, the performance-based criteria have not been satisfied. |
4. The option becomes fully-vested and may be exercised at any time at Holder's election upon the achievement of performance-based criteria related to approval by the U.S. Food and Drug Administration of certain of the Company's products. As of the date of this filing, the performance-based criteria have not been satisfied. |
5. The option becomes fully-vested and may be exercised at any time at Holder's election upon the Company having one calendar quarter of positive EBITDA. As of the date of this filing, the performance-based criteria have not been satisfied. |
6. The option becomes fully-vested and may be exercised at any time at Holder's election upon the sale of a specified number of units of certain of the Company's products. As of the date of this filing, the performance-based criteria have not been satisfied. |
7. The option becomes fully-vested and may be exercised at any time at Holder's election upon the achievement of performance-based criteria related to approval by the U.S. Food and Drug Administration of certain of the Company's products. As of the date of this filing, the performance-based criteria have not been satisfied. |
8. The option becomes fully-vested and may be exercised at any time at Holder's election upon the Company having one calendar quarter of positive EBITDA. As of the date of this filing, the performance-based criteria have not been satisfied. |
9. The option becomes fully-vested and may be exercised at any time at Holder's election upon the sale of a specified number of units of certain of the Company's products. As of the date of this filing, the performance-based criteria have not been satisfied. |
10. The option becomes fully-vested and may be exercised at any time at Holder's election upon the achievement of performance-based criteria related to approval by the U.S. Food and Drug Administration of certain of the Company's products. As of the date of this filing, the performance-based criteria have not been satisfied. |
11. The entire option has become fully-vested and may be exercised at any time at the Holder's election. |
12. The option becomes fully-vested and may be exercised at any time at Holder's election upon the achievement of performance-based criteria related to approval by the U.S. Food and Drug Administration of certain of the Company's products. As of the date of this filing, the performance-based criteria have not been satisfied. |
13. The option becomes fully-vested and may be exercised at any time at Holder's election upon the receipt of at least $15 million pursuant to the Company's sale of debt or equity securities or borrowings from any debt financing source. As of the date of this filing, the performance-based criteria have not been satisfied. |
14. The entire option has become fully-vested and may be exercised at any time at the Holder's election. |
15. The option becomes fully-vested and may be exercised at any time at Holder's election upon the achievement of performance-based criteria related to approval by the U.S. Food and Drug Administration of certain of the Company's products. As of the date of this filing, the performance-based criteria have not been satisfied. |
Remarks: |
Chief Operating Officer and Secretary |
/s/ Mark Hilz | 06/14/2022 | |
** 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 5 (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). | ||
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. | ||
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. |