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Ownership Document
|
| Schema Version: X0508 |
| Document Type: 4 |
| Period of Report: 10/2/23 |
| Not Subject to Section 16: 0 |
| Issuer: |
| Issuer CIK: 1138476 |
| Issuer Name: PACIFIC HEALTH CARE ORGANIZATION INC |
| Issuer Trading Symbol: PFHO |
| Reporting Owner: |
| Reporting Owner ID: |
| | Owner CIK: 1271519 |
| | Owner Name: KUBOTA TOM |
| Reporting Owner Address: |
| | Owner Street 1: 2618 SAN MIGUEL DRIVE, #477 |
| | Owner Street 2: |
| | Owner City: NEWPORT BEACH |
| | Owner State: CA |
| | Owner ZIP Code: 92660 |
| | Owner State Description: |
| Reporting Owner Relationship: |
| | Is Director? Yes |
| | Is Officer? Yes |
| | Is Ten Percent Owner? Yes |
| | Is Other? No |
| | Officer Title: CEO & President |
| | Other Text: |
| Aff 10b5 One: 0 |
| Non-Derivative Table: |
| Non-Derivative Transaction: |
| | Security Title: |
| | | Value: Common |
| | Transaction Date: |
| | | Value: 10/2/23 |
| | Deemed Execution Date: |
| | Transaction Coding: |
| | | Transaction Form Type: 4 |
| | | Transaction Code: P |
| | | Equity Swap Involved? No |
| | Transaction Timeliness: |
| | Transaction Amounts: |
| | | Transaction Shares: |
| Value: 55,000 |
| | | Transaction Price Per Share: |
| Value: 0.80 |
| | | Transaction Acquired-Disposed Code: |
| Value: A |
| | Post-Transaction Amounts: |
| | | Shares Owned Following Transaction: |
| Value: 8,351,647 |
| | Ownership Nature: |
| | | Direct or Indirect Ownership: |
| Value: D |
| Footnote ID: F1 |
| Derivative Table: |
| Derivative Holding: |
| | Security Title: |
| | | Value: Series A Preferred |
| | Conversion or Exercise Price: |
| | | Value: 0 |
| | Exercise Date: |
| | | Footnote ID: F2 |
| | Expiration Date: |
| | | Footnote ID: F2 |
| | Underlying Security: |
| | | Underlying Security Title: |
| Value: Common Stock |
| | | Underlying Security Shares: |
| Value: 16,000 |
| Footnote ID: F2 |
| | Post-Transaction Amounts: |
| | | Shares Owned Following Transaction: |
| Value: 16,000 |
| | Ownership Nature: |
| | | Direct or Indirect Ownership: |
| Value: D |
| Footnote ID: F1 |
| Footnotes: |
| Footnote - F1: The Reporting Person holds the shares through the Tom Kubota Revocable Trust of 2013 (the "Trust"). The Reporting Person is the sole Trustee of the Trust. As such, the Reporting Person may be deemed to have voting and/or investment power over the shares held by the Trust and therefore may be deemed to be the beneficial owner of those shares. |
| Footnote - F2: The Series A Preferred Stock converts into Common Stock of the Issuer on a 1:1 basis at any time at the election of the Reporting Person and has no expiration date. |
| Owner Signature: |
| Signature Name: /s/ Tom Kubota |
| Signature Date: 10/3/23 |
