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)
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2. Date of Event Requiring Statement
(Month/Day/Year) 07/26/2018 |
3. Issuer Name and Ticker or Trading Symbol
ADIAL PHARMACEUTICALS, INC. [ ADIL ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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5. If Amendment, Date of Original Filed
(Month/Day/Year) |
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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 | 36,704 | I | Virga Ventures, LLC(1) |
Common Stock | 11,229 | I | Newman GST Trust FBO James W. Newman Jr.(2) |
Common Stock | 10,043 | I | Ivy Cottage Group, LLC(3) |
Common Stock | 3,288 | I | Rountop Limited Partnership, LLP(4) |
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 | 10/10/2017 | 12/31/2021 | Common Stock | 5,415 | $0.0054 | I | Virga Ventures, LLC(1) |
Warrant | 10/10/2017 | 12/31/2031 | Common Stock | 4,974 | $7.63 | I | Virga Ventures, LLC(1) |
Warrant | 10/10/2017 | 12/31/2031 | Common Stock | 2,372 | $7.63 | I | Newman GST Trust FBO James W. Newman Jr.(2) |
Warrant | 10/10/2017 | 12/31/2021 | Common Stock | 2,707 | $0.0054 | I | Rountop Limited Partnership, LLP |
Warrant | 10/10/2017 | 12/31/2031 | Common Stock | 708 | $7.63 | I | Rountop Limited Partnership, LLP |
Warrant | 10/10/2017 | 12/31/2031 | Common Stock | 1,186 | $7.63 | I | Ivy Cottage Group, LLC(3) |
Convertible Note | (5) | (5) | Common Stock | 5,178(5) | (5) | I | Ivy Cottage Group, LLC(3) |
Convertible Note | (6) | (6) | Common Stock | 21,715(6) | (6) | I | Virga Ventures, LLC(1) |
Convertible Note | (7) | (7) | Common Stock | 29,931(7) | (7) | I | Newman GST Trust FBO James W. Newman Jr.(2) |
Stock Option | 01/01/2018 | 06/30/2027 | Common Stock | 5,580(8) | $5.7 | D |
Explanation of Responses: |
1. The securities are owned directly by Virga Ventures, LLC. James W. Newman, Jr. is the sole member of Virga Ventures, LLC. |
2. The securities are held directly by the Newman GST Trust. James W. Newman, Jr. is the sole trustee of the Newman GST Trust. |
3. The securities are owned directly by Ivy Cottage Group, LLC. James W. Newman, Jr. is the sole member of Ivy Cottage Group, LLC. |
4. securities are owned directly by Rountop Limited Partnership, LLP. James W. Newman, Jr. is the general partner of Rountop Limited Partnership, LLP. |
5. 5,178 shares to be issued to Ivy Cottage Group, LLC upon consummation of this offering upon automatic conversion of a convertible note in the principal amount of $1,729.95 at a conversion price of $0.44 per share |
6. 21,715 shares to be issued to Virga Ventures, LLC upon consummation of this offering upon automatic conversion of a convertible note in the principal amount of $7,255.02 at a conversion price of $0.44 per share |
7. 29,931 shares to be issued to Ivy Cottage Group, LLC upon consummation of this offering upon automatic conversion of a convertible note in the principal amount of $10,000 at a conversion price of $0.44 per share |
8. The option has an exercise price of $5.70 per share and vests as to 1/6th of the grant on January 1, 2018 with the remaining shares vesting 1/36th on the first day of each month over the remaining 30 months. |
/s/ James W. Newman, Jr. | 07/26/2018 | |
** 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. |