Statement of Changes in Beneficial Ownership (4)
December 05 2019 - 6:24PM
Edgar (US Regulatory)
FORM 4
[ ]
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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3235-0287
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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
*
Kraws Jeffrey J |
2. Issuer Name and Ticker or Trading Symbol
Ra Medical Systems, Inc.
[
RMED
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
_____ Director _____ 10% Owner
__X__ Officer (give title below) _____ Other (specify below)
Co-President |
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(Last)
(First)
(Middle)
C/O RA MEDICAL SYSTEMS, INC., 2070 LAS PALMAS DRIVE |
3. Date of Earliest Transaction
(MM/DD/YYYY)
12/3/2019 |
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(Street)
CARLSBAD, CA 92011
(City)
(State)
(Zip)
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4. 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 Acquired, Disposed of, or Beneficially Owned
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1.Title of Security
(Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code
(Instr. 8)
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4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)
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7. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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Amount
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(A) or (D)
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Price
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| Common Stock | 12/4/2019 | | F(1) | | 38372 | D | $1.8219 (2) | 114131 (3) | D | |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 3) | 2. Conversion or Exercise Price of Derivative Security | 3. Trans. Date | 3A. Deemed Execution Date, if any | 4. Trans. 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 | 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 of Derivative Security: 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) | $1.22 | 12/3/2019 | | A | | 139052 | | (4) | 12/3/2029 | Common Stock | 139052 | $0.00 | 139052 | D | |
| Explanation of Responses: |
| (1) | Shares withheld by the issuer to satisfy the mandatory tax withholding requirement upon vesting of restricted stock units. This is not an open market sale of securities. |
| (2) | Represents the weighted share price of an aggregate total of 38,372 shares withheld in the price range of $1.69 to $1.96 by the reporting person. The reporting person undertakes to provide upon request by the Commission staff, the issuer or a security holder of the issuer, full information regarding the number of shares withheld at each separate price. |
| (3) | Of the reported shares 2,315 shares are represented by Restricted Stock Units. |
| (4) | 1/36 of the total shares subject to the option shall vest every month after December 3, 2019, such that all shares shall be fully vested on December 3, 2022, subject to the Reporting Person continuing to be a "Service Provider" (as defined in the Company's 2018 Equity Incentive Plan) through each vesting date. |
Reporting Owners
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| Reporting Owner Name / Address | Relationships |
| Director | 10% Owner | Officer | Other |
Kraws Jeffrey J
C/O RA MEDICAL SYSTEMS, INC.
2070 LAS PALMAS DRIVE
CARLSBAD, CA 92011 |
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| Co-President |
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Signatures
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| /s/ Daniel Horwood, as Attorney-in-Fact | | 12/5/2019 |
| **Signature of Reporting Person | Date |
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