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*
NC 143 Family Holdings, LP

(Last) (First) (Middle)
1565 N. CENTRAL EXPRESSWAY, SUITE 200

(Street)
RICHARDSON TX 75080

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
Fuse Medical, Inc. [ FZMD ]
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)
12/29/2017
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 12/29/2016 P 50,000,000 A $0.2 55,000,000 D(1)
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*
NC 143 Family Holdings, LP

(Last) (First) (Middle)
1565 N. CENTRAL EXPRESSWAY, SUITE 200

(Street)
RICHARDSON TX 75080

(City) (State) (Zip)
1. Name and Address of Reporting Person*
Medtech Family Trust

(Last) (First) (Middle)
1565 NORTH CENTRAL EXPWY, SUITE 200

(Street)
RICHARDSON TX 75080

(City) (State) (Zip)
1. Name and Address of Reporting Person*
NC 143 Family Holdings GP LLC

(Last) (First) (Middle)
1565 NORTH CENTRAL EXPWY, SUITE 200

(Street)
RICHARDSON TX 75080

(City) (State) (Zip)
Explanation of Responses:
1. These securities are directly owned by NC 143 Family Holdings, LP, a Texas limited partnership ("NC 143"). However, both the Medtech Family Trust dated October 1, 2014 ("Medtech"), and NC 143 Family Holdings GP LLC (the "GP") indirectly own the reported securities. Medtech is the sole manager of the GP and the GP is the sole general partner of NC 143. Accordingly, both Medtech and the GP indirectly beneficially own the reported securities. This Form 4 is filed jointly by NC 143, Medtech, and the GP.
Remarks:
/s/ Mark W. Brooks 01/26/2018
** 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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