SEC Form 3
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*
Ells Valerie

(Last) (First) (Middle)
C/O LAIRD SUPERFOOD
275 W LUNDGREN MILL DR

(Street)
SISTERS OR 97759

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
09/22/2020
3. Issuer Name and Ticker or Trading Symbol
Laird Superfood, Inc. [ LSF ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director 10% Owner
X Officer (give title below) Other (specify below)
Chief Financial Officer
5. 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 Beneficially Owned
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 1,172 D
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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
Stock Option (right to buy) (1) 03/10/2028 Common Stock 20,000 9 D
Series A-1 Preferred Stock (2) (2) Common Stock 14,600 (2) D
Stock Option (right to buy) (3) 06/14/2028 Common Stock 2,000 9 D
Stock Option (right to buy) (4) 04/30/2029 Common Stock 18,000 12.315 D
Stock Option (right to buy) (5) 12/31/2029 Common Stock 20,000 14.5 D
Stock Option (right to buy) (6) 04/14/2030 Common Stock 9,940 13.05 D
Explanation of Responses:
1. Stock option granted under the 2016 Stock Incentive Plan ("Stock Plan") on March 11, 2018 and first became exercisable with respect to 25% of the shares of common stock on April 1, 2019 and has become and will become exercisable in equal parts on each of the first three anniversaries thereafter.
2. Each share of the Company's Series A-1 Preferred Stock is convertible on a one-to-two basis into shares of the Company's common stock at the holder's election and has no expiration date. The Series A-1 Preferred Stock will automatically convert into common stock upon the closing of the Company's initial public offering.
3. Stock option granted under the Stock Plan on June 15, 2018 and has become and will become exercisable, as applicable, with respect to 25% of the shares of common stock on each of the first four anniversaries of the date of grant.
4. Stock option granted under the 2018 Equity Incentive Plan ("Equity Plan") on May 1, 2019 and has become and will become exercisable, as applicable, with respect to 25% of the shares of common stock on each of the first four anniversaries of the date of grant.
5. Stock option granted under the Equity Plan on January 1, 2020 and becomes exercisable with respect to 25% of the shares of common stock on each of the first four anniversaries of the date of grant.
6. Stock option granted under the Equity Plan on April 15, 2020 and becomes exercisable with respect to approximately 25% of the shares of common stock on each of the first four anniversaries of the date of grant.
Remarks:
/s/ Andrew McCormick, as attorney-in-fact for Valerie Ells 09/22/2020
** 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.
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