SEC Form 5
FORM 5 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

ANNUAL 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
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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).
  
Form 3 Holdings Reported.
  
Form 4 Transactions Reported.
1. Name and Address of Reporting Person*
Buttorff Leslie

(Last) (First) (Middle)
5910 SOUTH UNIVERSITY BLVD, C18-193

(Street)
GREENWOOD VILLAGE CO 80121

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
PANACEA LIFE SCIENCES HOLDINGS, INC. [ PLSH ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director X 10% Owner
X Officer (give title below) Other (specify below)
Chief Executive Officer
3. Statement for Issuer's Fiscal Year Ended (Month/Day/Year)
12/31/2021
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 at end of Issuer's Fiscal Year (Instr. 3 and 4) 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 7. Nature of Indirect Beneficial Ownership (Instr. 4)
Amount (A) or (D) Price
Common Stock 12/21/2021 P 500 A $0.9998 600,399 D
Common Stock 12/21/2021 P 1,000 A $0.9024 601,399 D
Common Stock 10/25/2021 D 7,321,429 D (1) 4,047,054 I Held by Quintel-MC, Incorporated
Series C Preferred Stock 1,000,000 I Held by Quintel-MC, Incorporated
Series C-1 Preferred Stock 10,000 I Held by Quintel-MC, Incorporated
Series C-2 Preferred Stock(2) 10/25/2021 A 100 A (3) 100 I Held by Quintel-MC, Incorporated
Series D Preferred Stock 10,000 I Held by J&N Real Estate Company LLC
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)
(A) (D) Date Exercisable Expiration Date Title Amount or Number of Shares
Explanation of Responses:
1. The shares of common stock were cancelled in connection with the designation of 100 shares of Series C-2 Convertible Preferred Stock to Quintel-MC, Incorporated.
2. The Series C-2 designates 100 shares for issuance, par value $0.0001 per share. Each share of Series C-2 is convertible into 73,215 shares of the Company's common stock and is entitled to vote on all matters submitted to the Company's stockholders on an as-converted basis. Other than the conversion and voting rights, there are no other preferences.
3. The shares of preferred stock were acquired in connection with the cancellation of 7,321,429 shares of the Company's common stock that were held by Quintel-MC, Incorporated.
/s/ Leslie Buttorff 02/14/2022
** 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).
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