Initial Statement of Beneficial Ownership (3)
June 27 2019 - 2:20PM
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
OMB Number:
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
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Wolin Kim Patrice
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2. Date of Event Requiring Statement (MM/DD/YYYY)
6/17/2019
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3. Issuer Name
and
Ticker or Trading Symbol
SenesTech, Inc. [SNES]
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(Last)
(First)
(Middle)
C/O SENESTECH, INC., 3140 N. CADEN COURT, SUITE 1
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4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director
_____ 10% Owner
___
X
___ Officer (give title below)
_____ Other (specify below)
EVP & Secretary /
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(Street)
FLAGSTAFF, AZ 86004
(City)
(State)
(Zip)
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5. If Amendment, Date Original Filed
(MM/DD/YYYY)
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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)
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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
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117265.0000
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I
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Kim Patrice Wolin Revocable Trust
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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)
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2. Date Exercisable and Expiration Date
(MM/DD/YYYY)
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3. Title and Amount of Securities Underlying Derivative Security
(Instr. 4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
(Instr. 5)
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6. Nature of Indirect Beneficial Ownership
(Instr. 5)
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Date Exercisable
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Expiration Date
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Title
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Amount or Number of Shares
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Stock Option (right to buy)
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1/6/2016
(1)
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11/16/2025
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Common Stock
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105000.0000
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$0.5000
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D
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Stock Option (right to buy)
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7/3/2016
(2)
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7/3/2025
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Common Stock
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20000.0000
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$0.5000
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D
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Explanation of Responses:
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(1)
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55,000 shares subject to the option vested on January 6, 2016 and an additional 25,000 vested on each of May 7, 2016 and May 7, 2017, subject to continuous service.
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(2)
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Date at which first vesting occurs is indicated. One-fourth of the total shares subject to the option vested on the first vesting date with the remaining portion vesting in equal monthly tranches over the next 36 months of continuous service.
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Remarks:
Exhibit 24 Power of Attorney filed herewith.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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Wolin Kim Patrice
C/O SENESTECH, INC.
3140 N. CADEN COURT, SUITE 1
FLAGSTAFF, AZ 86004
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EVP & Secretary
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Signatures
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/s/ William Baker as Attorney-in-Fact
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6/27/2019
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 5(b)(v).
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**
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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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Note:
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File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure.
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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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