Amended Statement of Beneficial Ownership (3/a)
January 17 2020 - 5:10PM
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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0.5
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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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Kruse William R |
2. Date of Event Requiring Statement (MM/DD/YYYY)
12/24/2019
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3. Issuer Name and Ticker or Trading Symbol
PreCheck Health Services, Inc. [HLTY]
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(Last)
(First)
(Middle)
1340 S. MAIN ST., SUITE 300 |
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director ___X___ 10% Owner _____ Officer (give title below) _____ Other (specify below)
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(Street)
GRAPEVINE, TX 76051
(City)
(State)
(Zip)
| 5. If Amendment, Date Original Filed(MM/DD/YYYY) 1/7/2020
| 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, par value $0.0001 per share | 1621701 | D | |
Common stock, par value $0.0001 per share | 232820 | I | Jointly with spouse |
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 |
(1) (1) | (1) | (1) | (1) (1) | (1) | (1) | D | |
common stock purchase warrant | 4/2/2019 | 4/2/2022 | Common stock | 125000 | $1.00 | D | |
Explanation of Responses: |
(1) | On March 20, 2018, the Company issued to Mr. Kruse for $75,000 a convertible note for $80,250 and warrants to purchase 75,000 shares of common stock at $1.20 per share, subject to adjustment. On September 30, 2018, the Company entered into a note amendment with the note settlement amount amended to $90,000 and note expiry date extended to March 30, 2019. The Company and Mr. Kruse entered into extension agreements, most recently on January 6, 2020 extending to June 20, 2020, the date on which the note is to be paid. Pursuant to the extension agreement, Mr. Kruse agreed not to convert the note or exercise the warrant prior to June 30, 2020, to sell the Note to the Company for $90,000 and to either accept $12,500 or 37,500 shares in exchange for the warrant. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Kruse William R 1340 S. MAIN ST. SUITE 300 GRAPEVINE, TX 76051 |
| X |
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Signatures
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/s/ William R. Kruse | | 1/17/2020 |
**Signature of Reporting Person | Date |