Form 4 Chf Solutions, Inc.

4 - Statement of changes in beneficial ownership of securities

Filed: 2017-11-29 16:54:27
Dated: 2017-11-29
Period of Report: 2017-11-22
primary_doc.html PRIMARY DOCUMENT


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
Estimated average burden
hours per response: 0.5
  
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*
ERB JOHN L

(Last) (First) (Middle)
12988 VALLEY VIEW ROAD

(Street)
EDEN PRAIRIE MN 55344

(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)
X Director 10% Owner
X Officer (give title below) Other (specify below)
CEO and President
3. Date of Earliest Transaction (Month/Day/Year)
11/22/2017
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
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
Series F Convertible Preferred Stock $4.5 11/22/2017 P 100 11/22/2017 (1) Common Stock 22,222 (2) 100 D
Series 1 Warrant to Purchase Common Stock (right to buy) $4.5 11/22/2017 P 100 11/22/2017 11/22/2018 Common Stock 22,300 (2) 100 D
Series 2 Warrant to Purchase Common Stock (right to buy) $4.5 11/22/2017 P 100 11/22/2017 11/22/2024 Common Stock 22,300 (2) 100 D
Explanation of Responses:
1. The Series F Convertible Preferred Stock (the "Preferred Stock") has no expiration date.
2. The reporting person purchased the Preferred Stock for $995.54 per share in an underwritten public offering that closed on November 27, 2017. For each share of Preferred Stock purchased, the reporting person also received one warrant to purchase 223 shares of common stock (the Series 1 warrant), and one warrant to purchase 223 shares of common stock (the Series 2 warrant). The Preferred Stock and warrants were issued separately.
Gayle C. Aiken, by Power of Attorney 11/29/2017
** 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
Additional Files
FileSequenceDescriptionTypeSize
0001596771-17-000088.txt   Complete submission text file   10070
primary_doc.xml 1 PRIMARY DOCUMENT 4 8594
$CHFS

© 2019 SEC.report
This site is not affiliated with or endorsed by the SEC.
The SEC operates under the authority of Title 17 of the Code of Federal Regulations.