Form 4 Choi Ki Yong

4 - Statement of changes in beneficial ownership of securities

Published: 2017-10-13 20:06:20
Submitted: 2017-10-13
Period Ending In: 2017-10-11
tv476993_4.html FORM 4


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SEC FORM 4

SEC Form 4
FORM 4 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934
or Section 30(h) of the Investment Company Act of 1940
OMB APPROVAL
OMB Number: 3235-0287
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
1. Name and Address of Reporting Person*
Choi Ki Yong

(Last) (First) (Middle)
36 GREAT CIRCLE DRIVE

(Street)
MILL VALLEY CA 94941

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
CHF Solutions, Inc. [ CHFS ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director X 10% Owner
Officer (give title below) Other (specify below)
3. Date of Earliest Transaction (Month/Day/Year)
10/11/2017
4. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security (Instr. 3) 2. Transaction Date (Month/Day/Year) 2A. Deemed Execution Date, if any (Month/Day/Year) 3. Transaction Code (Instr. 8) 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 7. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V Amount (A) or (D) Price
Common Stock 10/11/2017 P 31,504 A $0.56 1,762,968 D
Common Stock 10/12/2017 P 30,141 A $0.48 1,793,109 D
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 3) 2. Conversion or Exercise Price of Derivative Security 3. Transaction Date (Month/Day/Year) 3A. Deemed Execution Date, if any (Month/Day/Year) 4. Transaction 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 (Month/Day/Year) 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: 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
Explanation of Responses:
/s/ Ki Yong Choi 10/12/2017
** 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 4 (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.
1
tv476993_4.xml FORM 4
Schema Version:
X0306
Document Type:
4
Period Of Report:
2017-10-11
Not Subject To Section16:
0

Issuer

Issuer Cik
0001506492
Issuer Name
CHF Solutions, Inc.
Issuer Trading Symbol
CHFS

Reporting Owner

Reporting Owner Id

Rpt Owner Cik
0001407536
Rpt Owner Name
Choi Ki Yong

Reporting Owner Address

Rpt Owner Street1
36 GREAT CIRCLE DRIVE
Rpt Owner City
MILL VALLEY
Rpt Owner State
CA
Rpt Owner Zip Code
94941

Reporting Owner Relationship

Is Director
0
Is Officer
0
Is Ten Percent Owner
1
Is Other
0

Non Derivative Transaction

Security Title
Common Stock
Transaction Date
2017-10-11

Transaction Coding

Transaction Form Type
4
Transaction Code
P
Equity Swap Involved
0

Transaction Amounts

Transaction Shares
31504
Transaction Price Per Share
0.56
Transaction Acquired Disposed Code
A
Shares Owned Following Transaction
1762968
Direct Or Indirect Ownership
D
Security Title
Common Stock
Transaction Date
2017-10-12

Transaction Coding

Transaction Form Type
4
Transaction Code
P
Equity Swap Involved
0

Transaction Amounts

Transaction Shares
30141
Transaction Price Per Share
0.48
Transaction Acquired Disposed Code
A
Shares Owned Following Transaction
1793109
Direct Or Indirect Ownership
D

Owner Signature

Signature Name
/s/ Ki Yong Choi
Signature Date
2017-10-12
Additional Files
FileSequenceDescriptionTypeSize
0001144204-17-052491.txt   Complete submission text file   5936
$CHFS

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