SEC Form 3
FORM 3 | UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES 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*
(Street)
| 2. Date of Event Requiring Statement (Month/Day/Year) 08/13/2019 | 3. Issuer Name and Ticker or Trading Symbol AngioSoma, Inc. [ SOAN ] | |||||||||||||
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
| 5. If Amendment, Date of Original Filed (Month/Day/Year) | ||||||||||||||
6. Individual or Joint/Group Filing (Check Applicable Line)
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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 Shares | 1,500,000 | I | Equine Charter Private Equity Fund XII(1) |
Common Shares | 1,000,000 | I | Equine Charter Private Equity Fund XI(1) |
Common Shares | 4,522,812 | I | Cargill-Atwood Family Private Equity Fund, LLC |
Common Shares | 50,000 | I | Goddard Investment Company PE Fund XIX(1) |
Common Shares | 250,000 | I | Equine Private Equity Fund LXXVII (77) LLC(1) |
Common Shares | 1,250,000 | I | Equine Charter Private Equity Fund XV, LLC |
Common Shares | 1,400,000 | I | Equine Charter Private Equity Fund DCCCLXXXVIII, LLC(1) |
Common Shares | 170,000 | I | Family Trust |
Common Shares | 2,900,469 | I | Equine Private Equity Fund 755460, LLC(1) |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
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1. Title of Derivative Security (Instr. 4) | 2. Date Exercisable and Expiration Date (Month/Day/Year) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form: 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 |
Explanation of Responses: |
1. Brent Atwood is the Chief Executive Manager of Equine Holdings, LLC ("Holdings") and each of the following entities: Equine Charter Private Equity Fund XII, Equine Charter Private Equity Fund XI, Goddard Investment Company PE Fund XIX, Equine Private Equity Fund LXXVII (77) LLC, Equine Charter Private Equity Fund XV, LLC, Equine Charter Private Equity Fund DCCCLXXXVIII, LLC and Equine Private Equity Fund 755460, LLC (the "Equine Entities"). Holdings also serves as the manager of, and holds a 1% interest in each of the Equine Entities. Mr. Atwood and Holdings each disclaim beneficial ownership of the reported securities except to the extent of their pecuniary interest therein. |
/s/ Brent Atwood | 08/15/2019 | |
** 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 Number. |