-----BEGIN PRIVACY-ENHANCED MESSAGE----- Proc-Type: 2001,MIC-CLEAR Originator-Name: webmaster@www.sec.gov Originator-Key-Asymmetric: MFgwCgYEVQgBAQICAf8DSgAwRwJAW2sNKK9AVtBzYZmr6aGjlWyK3XmZv3dTINen TWSM7vrzLADbmYQaionwg5sDW3P6oaM5D3tdezXMm7z1T+B+twIDAQAB MIC-Info: RSA-MD5,RSA, UOfla/eZ4kQpfzO3m7AR7bktXAr+9Susm3at/KhScxOkI86QkkulZWT3XRTA3GXu sXOlasdG7S2+nOUus6BrXw== 0001005477-04-003419.txt : 20040923 0001005477-04-003419.hdr.sgml : 20040923 20040923172651 ACCESSION NUMBER: 0001005477-04-003419 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20040913 FILED AS OF DATE: 20040923 DATE AS OF CHANGE: 20040923 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Aholt Robert Joseph JR CENTRAL INDEX KEY: 0001304011 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 000-10909 FILM NUMBER: 041043539 BUSINESS ADDRESS: BUSINESS PHONE: 310 748-1734 MAIL ADDRESS: STREET 1: 20128 CAVERN COURT CITY: SAUGUS STATE: CA ZIP: 91390 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: PHASE III MEDICAL INC/DE CENTRAL INDEX KEY: 0000320017 STANDARD INDUSTRIAL CLASSIFICATION: INSURANCE CARRIERS, NEC [6399] IRS NUMBER: 222343568 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 330 SOUTH SERVICE ROAD STREET 2: SUITE 120 CITY: MELVILLE STATE: NY ZIP: 11747 BUSINESS PHONE: 6315744955 MAIL ADDRESS: STREET 1: 330 SOUTH SERVICE ROAD STREET 2: SUITE 120 CITY: MELVILLE STATE: NY ZIP: 11747 FORMER COMPANY: FORMER CONFORMED NAME: CORNICHE GROUP INC /DE DATE OF NAME CHANGE: 19951117 FORMER COMPANY: FORMER CONFORMED NAME: FIDELITY MEDICAL INC DATE OF NAME CHANGE: 19951025 FORMER COMPANY: FORMER CONFORMED NAME: FIDELITY MEDICAL SERVICES INC DATE OF NAME CHANGE: 19830825 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Aholt Jr Family Trust CENTRAL INDEX KEY: 0001304164 STATE OF INCORPORATION: CA FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 000-10909 FILM NUMBER: 041043538 BUSINESS ADDRESS: STREET 1: 20128 CAVERN COURT CITY: SAUGUS STATE: CA ZIP: 91390 BUSINESS PHONE: 310 748-1734 MAIL ADDRESS: STREET 1: 20128 CAVERN COURT CITY: SAUGUS STATE: CA ZIP: 91390 3 1 edgar123.xml FORM 3 X0202 3 2004-09-13 0 0000320017 PHASE III MEDICAL INC/DE PHSM 0001304011 Aholt Robert Joseph JR 20128 CAVERN COURT SAUGUS CA 91390 0 1 1 0 Chief Operating Officer 0001304164 Aholt Jr Family Trust 20128 CAVERN COURT SAUGUS CA 91390 0 0 1 0 common stock, par value $0.001 per share 7282913 I See footnote number 2 common stock, par value $0.001 per share 0 D Aholt, Jr. Family Trust dated 2/17/97 (the "Trust") acquired these shares pursuant to the terms of a subscription agreement (as amended, modified or supplemented, the "Subscription Agreement"), dated September 13, 2004, between Phase III Medical, Inc. (the "Company") and the Trust. The address of the Trust is 20128 Cavern Court, Saugus, California 91390. These shares are owned directly by the Trust, holder of more than 10% of the shares of common stock, par value $0.001 per share, of the Company ("Common Stock"), outstanding as of the date hereof, and indirectly by Robert J. Aholt, Jr., as trustee of the Trust. Mr. Aholt is the chief operating officer of the Company and, by virtue of his position as trustee of the Trust, holder of more than 10% of the shares of Common Stock outstanding as of the date hereof. Pursuant to the Subscription Agreement, the Company and Mr. Aholt agreed that upon maturity of a promissory note made by the Company in favor of Mr. Aholt on August 30, 2004 (the "Note"), the Company will repay the Note in shares of Common Stock, at a per share conversion price equal to 85% of the average of the closing price of one share of Common Stock on the National Association of Securities Dealers, Inc. Over-the-Counter Bulletin Board (the "Bulletin Board") for the five (5) days immediately preceding the maturity date of the Note, or, if the Common Stock is not then traded on the Bulletin Board, at 85% of fair market value as determined by the Board of Directors of the Company. The Note, which was made in the principal amount of $100,000, bears interest at a rate of 20% per annum and matures on February 28, 2005. The interests in these shares are owned directly by Mr. Aholt. /s/ Robert J. Aholt, Jr., Individually 2004-09-23 /s/ Robert J. Aholt, Jr., as Trustee for Aholt, Jr. Family Trust dated 2/17/97 2004-09-23 -----END PRIVACY-ENHANCED MESSAGE-----