Initial Statement of Beneficial Ownership (3)
June 27 2022 - 8:44AM
Edgar (US Regulatory)
FORM 3
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
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3235-0104
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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
*
Jacob Jeffrey E. |
2. Date of Event Requiring Statement (MM/DD/YYYY)
6/15/2022
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3. Issuer Name and Ticker or Trading Symbol
Panbela Therapeutics, Inc. [PBLA]
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(Last)
(First)
(Middle)
712 VISTA BLVD #305 |
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
__X__ Director _____ 10% Owner
_____ Officer (give title below) _____ Other (specify below)
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(Street)
WACONIA, MN 55387
(City)
(State)
(Zip)
| 5. If Amendment, Date Original Filed(MM/DD/YYYY)
| 6. Individual or Joint/Group Filing(Check Applicable Line)
_X_ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person
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Table I - Non-Derivative Securities Beneficially Owned
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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) |
| Common Stock | 261931 | D | |
| Common Stock | 17771 | I | Jointly with spouse |
| Common Stock | 54374 | I | By trust |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 4) | 2. Date Exercisable and Expiration Date
(MM/DD/YYYY) | 3. Title and Amount of Securities Underlying Derivative Security
(Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form of Derivative Security: 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) | 9/26/2022 | Common Stock | 41766 | $1.2400 | D | |
| Stock Option (right to buy) | (1) | 9/26/2022 | Common Stock | 35543 | $1.4700 | D | |
| Stock Option (right to buy) | (1) | 12/28/2030 | Common Stock | 91523 | $0.2200 | D | |
| Stock Option (right to buy) | (1) | 12/28/2030 | Common Stock | 177715 | $0.2200 | D | |
| Warrants (right to buy) | (1) | 2/1/2023 | Common Stock | 5174 | $5.6300 | I | By trust |
| Explanation of Responses: |
| (1) | Fully vested. |
Remarks:
Exhibit List: Power for Attorney EX-24 |
Reporting Owners
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| Reporting Owner Name / Address | Relationships |
| Director | 10% Owner | Officer | Other |
Jacob Jeffrey E.
712 VISTA BLVD #305
WACONIA, MN 55387 | X |
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Signatures
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| /s/ Joshua L. Colburn, Attorney-in-Fact | | 6/25/2022 |
| **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 control number. |
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