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) 12/10/2021 | 3. Issuer Name and Ticker or Trading Symbol BASANITE, INC. [ BASA ] | |||||||||||||
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 Stock | 10,000 | D |
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 | ||||
Warrant | 12/10/2021 | 12/10/2026 | Restricted Common Stock | 20,000,000 | 0.33 | I | U.S. Supplies Inc.(1) |
Explanation of Responses: |
1. Manuel A. Rodriguez ("Mr. Rodriguez") is the President of U.S. Supplies, Inc. ("U.S. Supplies"). On December 10, 2021, in connection with certain agreements entered into between U.S. Supplies and Basanite, Inc. (the "Company"), U.S. Supplies was issued a warrant (the "Warrant") to purchase up to forty million (40,000,000) shares of restricted common stock of the Company beginning on December 10, 2021 and expiring on December 10, 2026. The right to purchase fifty percent (50%) of such shares (or 20,000,000 shares) vested on the grant date and the right to purchase the remaining fifty percent (50%) of such shares (or 20,000,000 shares) vests upon the satisfaction of a condition precedent as detailed in the Warrant. |
/s/ Manuel A. Rodriquez | 12/20/2021 | |
** 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. |