Initial Statement of Beneficial Ownership (3)
June 14 2021 - 6:14AM
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
*
Jensen Peter Michael |
2. Date of Event Requiring Statement (MM/DD/YYYY)
9/15/2020
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3. Issuer Name and Ticker or Trading Symbol
ROCKETFUEL BLOCKCHAIN, INC. [RKFL]
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(Last)
(First)
(Middle)
45 BULKLEY AVE, #3 |
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
__X__ Director _____ 10% Owner ___X___ Officer (give title below) _____ Other (specify below) CEO / |
(Street)
SAUSALITO, CA 94965
(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) |
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 |
Options to purchase Common Stock | 10/15/2020 | 9/15/2030 | Common Stock | 2393842 | $1.08 | D | |
Warrants to purchase Common Stock | 3/18/2021 | 3/18/2031 | Common Stock | 265982 | $1.00 | D | |
Explanation of Responses: |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Jensen Peter Michael 45 BULKLEY AVE, #3 SAUSALITO, CA 94965 | X |
| CEO |
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Signatures
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/s/ Peter M. Jensen | | 6/14/2021 |
**Signature of Reporting Person | Date |
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