SEC FORM
3
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
|
| OMB APPROVAL |
| OMB Number: |
3235-0104 |
| Estimated average burden |
| hours per response: |
0.5 |
|
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1. Name and Address of Reporting Person*
| 150 ALLEN ROAD, SUITE 201 |
|
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
06/21/2018
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3. Issuer Name and Ticker or Trading Symbol
electroCore, Inc.
[ ECOR ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
|
Director |
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10% Owner |
| X |
Officer (give title below) |
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Other (specify below) |
| Chief Medical Officer |
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5. If Amendment, Date of Original Filed
(Month/Day/Year)
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6. Individual or Joint/Group Filing (Check Applicable Line)
| X |
Form filed by One Reporting Person |
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Form filed by More than One Reporting Person |
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| Table I - Non-Derivative Securities Beneficially Owned |
|---|
| 1. Title of Security (Instr.
4)
|
2.
Amount of Securities Beneficially Owned (Instr.
4)
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3. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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4. Nature of Indirect Beneficial Ownership (Instr.
5)
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| Common Stock |
144,636 |
D |
|
| Common Stock |
6,597 |
I |
Via Spouse |
| Common Stock |
12,843 |
I |
via WaveCore LLC |
| Common Stock |
237,825 |
I |
via Core Ventures II, LLC |
| Common Stock |
55,542 |
I |
Via by Core Ventures IV, LLC |
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
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5. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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6. Nature of Indirect Beneficial Ownership (Instr.
5)
|
| Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
| Stock Option |
01/01/2019
|
06/22/2028 |
Common Stock |
130,935 |
15 |
D |
|
| Warrant |
06/29/2016 |
06/29/2021 |
Common Stock |
11,884 |
12.6 |
I |
via Core Ventures II, LLC |
| Explanation of Responses: |
|
| Remarks: |
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/s/ John L. Cleary, II, attorney-in-fact |
06/21/2018 |
|
** 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
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. |
POWER OF ATTORNEY
FOR SEC FILINGS ON FORMS ID, 3, 4, 5, 144, SCHEDULES 13D and 13G
IN RESPECT OF SECURITIES OF
ELECTROCORE, INC.
The undersigned hereby constitutes and appoints each of John Cleary, Ira Kotel,
Brian Lee and Chris Errico as his true and lawful attorneys-in-fact and agents,
each with full power of substitution and resubstitution for him in his name and
stead in any and all capacities, to sign and file for and on his behalf, in
respect of any acquisition, disposition or other change in ownership of any
Common Stock or derivative securities thereof of electroCore, Inc. (the
"Company"), the following:
(i) any Form ID to be filed with the Securities and Exchange Commission (the
"SEC");
(ii) any Initial Statement of Beneficial Ownership of Securities on Form 3 to be
filed with the SEC;
(iii) any Statement of Changes of Beneficial Ownership of Securities on Form 4
to be filed with the SEC;
(iv) any Annual Statement of Beneficial Ownership of Securities on Form 5 to be
filed with the SEC;
(v) any Notice of Proposed Sale of Securities on Form 144 to be filed with the
SEC
(vi) and any other forms or reports the undersigned may be required to file in
connection with the undersigned's ownership, acquisition or disposition of
securities of the Company, including Schedules 13G and 13D; and
(vii) any and all agreements, certificates, receipts, or other documents in
connection therewith. The undersigned hereby gives full power and authority to
each attorney-in-fact to seek and obtain as the undersigned's representative and
on the undersigned's behalf, information on transactions in the Company's
securities from any third party, including brokers, employee benefit plan
administrators and trustees, and the undersigned hereby authorizes any such
person to release such information to the undersigned and approves and ratifies
any such release of information. The undersigned hereby grants unto each
attorney-in-fact and agent full power and authority to do and perform each and
every act and thing requisite and necessary in connection with such matters and
hereby ratifies and confirms all that any such attorney-in-fact and agent or
substitute may do or cause to be done by virtue hereof. The undersigned
acknowledges that:
(i) neither the Company nor any of such attorney-in-fact assumes (i) any
liability for the undersigned's responsibility to comply with the requirement of
the Securities Exchange Act of 1934, as amended (the "Exchange Act"), (ii) any
liability of the undersigned for any failure to comply with such requirements or
(iii) any obligation or liability of the undersigned for profit disgorgement
under Section 16(b) of the Exchange Act; and
(ii) this Power of Attorney does not relieve the undersigned from responsibility
for compliance with the undersigned's obligations under the Exchange Act,
including without limitation the reporting requirements under Section 16 of the
Exchange Act. This Power of Attorney shall remain in full force and effect until
revoked by the undersigned in a signed writing delivered to such
attorney-in-fact.
IN WITNESS WHEREOF, the undersigned has executed this Power of Attorney.
Date: June 18, 2018 /s/ Peter Staats
Peter Staats
