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*
Barack Louis Jon

(Last) (First) (Middle)
C/O JUSHI HOLDINGS INC.
301 YAMATO ROAD, SUITE 3250

(Street)
BOCA RATON FL 33431

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
08/12/2022
3. Issuer Name and Ticker or Trading Symbol
Jushi Holdings Inc. [ JUSH/JUSHF ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director 10% Owner
X Officer (give title below) Other (specify below)
Pres., Corp. Secy., INT CFO
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)
Subordinate Voting Shares 2,821,773 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) 10/27/2031 Subordinate Voting Shares 920,000 $3.91 D
Stock Option (right to buy) (1) 10/27/2031 Subordinate Voting Shares 80,000 $3.91 D
Stock Option (right to buy) 04/17/2022 04/17/2029 Subordinate Voting Shares 793,000 $2 D
Stock Option (right to buy) (2) 07/28/2032 Subordinate Voting Shares 170,000 $1.93 D
Stock Option (right to buy) (2) 07/28/2032 Subordinate Voting Shares 830,000 $1.93 D
Warrant (right to buy) 06/10/2019 06/10/2029 Subordinate Voting Shares 1,500,000 $1 D
Explanation of Responses:
1. This Option will vest as to 33 1/3% of the total number of Shares subject to the Option on each yearly anniversary after the Vesting Commencement Date (5/1/2021), subject to continuous service.
2. This Option will vest as to 33 1/3% of the total number of Shares subject to the Option on each yearly anniversary after the Vesting Commencement Date (5/1/2022), subject to continuous service.
Remarks:
Exhibit 24 - Power of Attorney
/s/ James Cacioppo, attorney-in-fact 08/12/2022
** 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.