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*
William H.C. Chang & Diana Shon Chang TTEE Chang Family Trust U/A DTD 10/23/2006

(Last) (First) (Middle)
C/O SEMLER SCIENTIFIC, INC.
911 BERN COURT, SUITE 110.

(Street)
SAN JOSE CA 95112

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
Semler Scientific, Inc. [ SMLR ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director X 10% Owner
Officer (give title below) Other (specify below)
3. Date of Earliest Transaction (Month/Day/Year)
09/03/2019
4. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
Form filed by One Reporting Person
X 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
Common Stock 09/03/2019 G V 600,000 D $0 711,134 D(1)(2)
Common Stock 09/03/2019 G V 300,000 A $0 300,000 D(2)(3)
Common Stock 09/03/2019 G V 300,000 A $0 300,000 D(2)(4)
Common Stock 10/09/2019 G V 300,000 D $0 411,134 D(1)(5)
Common Stock 10/09/2019 G V 150,000 D $0 450,000 D(5)(6)
Common Stock 10/09/2019 G V 150,000 D $0 450,000 D(5)(7)
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
1. Name and Address of Reporting Person*
William H.C. Chang & Diana Shon Chang TTEE Chang Family Trust U/A DTD 10/23/2006

(Last) (First) (Middle)
C/O SEMLER SCIENTIFIC, INC.
911 BERN COURT, SUITE 110.

(Street)
SAN JOSE CA 95112

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
Director X 10% Owner
Officer (give title below) Other (specify below)
1. Name and Address of Reporting Person*
Chang William H

(Last) (First) (Middle)
C/O SEMLER SCIENTIFIC, INC.
911 BERN COURT, SUITE 110

(Street)
SAN JOSE CA 95112

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
Director X 10% Owner
Officer (give title below) Other (specify below)
1. Name and Address of Reporting Person*
Chang Diana Shon

(Last) (First) (Middle)
C/O SEMLER SCIENTIFIC, INC.
911 BERN COURT, SUITE 110

(Street)
SAN JOSE CA 95112

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
Director X 10% Owner
Officer (give title below) Other (specify below)
Explanation of Responses:
1. Shares are held directly by William H.C. Chang & Diana Shon Chang TTEE Chang Family Trust U/A DTD 10/23/2006 (the "Trust").
2. On September 3, 2019 the Trust contributed an aggregate 600,000 shares of the Issuer's common stock to six separate grantor retained annuity trusts ("GRATS"), 100,000 shares each, for which Mrs. Chang acts as sole Trustee of three GRATs and has retained sole voting and dispositive power as to 300,000 shares, and for which Mr. Chang acts as sole Trustee of three GRATs and has retained sole voting and dispositive power as to 300,000 shares.
3. Shares are held in three GRATs, for which Mr. Chang acts as sole Trustee and has voting and investment control.
4. Shares are held in three GRATs, for which Mrs. Chang acts as sole Trustee and has voting and investment control.
5. On October 9, 2019 the Trust contributed an aggregate 300,000 shares of the Issuer's common stock to six separate GRATS, 50,000 shares each, for which Mrs. Chang acts as sole Trustee of three GRATs and has retained sole voting and dispositive power as to 150,000 shares, and for which Mr. Chang acts as sole Trustee of three GRATs and has retained sole voting and dispositive power as to 150,000 shares.
6. Shares are held in three GRATs (separate from those referenced in footnote 3), for which Mr. Chang acts as sole Trustee and has voting and investment control.
7. Shares are held in three GRATs (separate from those referenced in footnote 4), for which Mrs. Chang acts as sole Trustee and has voting and investment control.
/s/ William H.C. Chang, Co-Trustee 11/14/2019
/s/ William H.C. Chang 11/14/2019
/s/ Diana Shon Chang 11/14/2019
** 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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