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
OMB APPROVAL
OMB Number: 3235-0287
Estimated average burden
hours per response: 0.5
  
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*
BRATTON DOUGLAS K

(Last) (First) (Middle)
201 MAIN STREET, SUITE 1900

(Street)
FORT WORTH TX 76102

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
MIDWEST HOLDING INC. [ MDWT ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director X 10% Owner
Officer (give title below) Other (specify below)
3. Date of Earliest Transaction (Month/Day/Year)
07/31/2020
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
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
Stock Option (right to buy) $0.05 07/31/2020 A 50,000(1) (1) 07/31/2020 Voting Common Stock 50,000 $0.00 50,000 I See Footnotes(2)(3)
1. Name and Address of Reporting Person*
BRATTON DOUGLAS K

(Last) (First) (Middle)
201 MAIN STREET, SUITE 1900

(Street)
FORT WORTH TX 76102

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
X Director X 10% Owner
Officer (give title below) Other (specify below)
1. Name and Address of Reporting Person*
CRESTLINE ASSURANCE HOLDINGS LLC

(Last) (First) (Middle)
201 MAIN STREET, SUITE 1900

(Street)
FORT WORTH TX 76102

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
X Director X 10% Owner
Officer (give title below) Other (specify below)
1. Name and Address of Reporting Person*
Crestline Management, LP

(Last) (First) (Middle)
201 MAIN STREET, SUITE 1900

(Street)
FORT WORTH TX 76102

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
X Director X 10% Owner
Officer (give title below) Other (specify below)
1. Name and Address of Reporting Person*
Crestline Investors, Inc.

(Last) (First) (Middle)
201 MAIN STREET, SUITE 1900

(Street)
FORT WORTH TX 76102

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
X Director X 10% Owner
Officer (give title below) Other (specify below)
Explanation of Responses:
1. Non-Qualified Stock Options granted under the Midwest Holding Inc. 2019 Long-Term Incentive Plan to Douglas K. Bratton for his service on the Board of Directors (the "Board") of Midwest Holding Inc. (the "Issuer"). The Non-Qualified Stock Options vest as follows: (i) 25,000 Options shall vest on July 31, 2022; and (ii) 25,000 Options shall vest on July 31, 2024, in each case subject to Mr. Bratton's continued service on the Issuer's Board.
2. Mr. Bratton serves on the Issuer's Board as a representative of Crestline Assurance Holdings LLC ("Crestline Assurance") and its affiliates. Mr. Bratton holds the Options reported herein for the benefit of Crestline Assurance and as a result does not have any direct pecuniary interest in such Options. Mr. Bratton may be deemed to have an indirect pecuniary interest in a portion of the Options through indirect membership interests in Crestline Assurance. The Manager of Crestline Assurance is Mr. Bratton and the Sole Member of Crestline Assurance is Crestline Management, L.P. ("Crestline Management"). Crestline Investors, Inc. ("Crestline") is the general partner of Crestline Management. Mr. Bratton is the sole director of Crestline. Crestline Management, Crestline and Mr. Bratton may each be deemed to beneficially own the securities beneficially owned by Crestline Assurance.
3. (Continued from Footnote 2) Each such entity and Mr. Bratton disclaims beneficial ownership of such securities except to the extent of its or his respective pecuniary interest therein.
Remarks:
Douglas K. Bratton is a member of the Board of Directors of Midwest Holding Inc. (the "Issuer"). For purposes of Section 16 of the Securities Exchange Act of 1934, as amended, Crestline Assurance Holdings LLC, Crestline Management, L.P. and Crestline Investors, Inc. may be deemed to be directors by deputization of the Issuer due to their relationship with Mr. Bratton.
DOUGLAS K. BRATTON, /s/ Douglas K. Bratton 08/04/2020
CRESTLINE ASSURANCE HOLDINGS LLC, /s/ Douglas K. Bratton, Title: Manager 08/04/2020
CRESTLINE MANAGEMENT, L.P., By: Crestline Investors, Inc., its general partner, /s/ Douglas K. Bratton, Title: Sole Director 08/04/2020
CRESTLINE INVESTORS, INC., /s/ Douglas K. Bratton, Title: Sole Director 08/04/2020
** 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 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).
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.