FORM 4
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN 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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(Print or Type Responses)
1. Name and Address of Reporting Person *
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Steinmetz Nicole Franziska |
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2. Issuer Name and Ticker or Trading Symbol Mosaic ImmunoEngineering Inc. [CPMV]
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5. Relationship of Reporting Person(s) to Issuer (Check all applicable)
__X__ Director
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__X__ 10% Owner
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__X__ Officer (give title below)
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_____ Other (specify below)
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Acting CSO
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1537 SOUTH NOVATO BLVD., #5 |
3. Date of Earliest Transaction (Month/Day/Year) 01/29/2021 |
NOVATO, CA 94947 |
4. If Amendment, Date Original Filed
(Month/Day/Year)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
_X_ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security (Instr. 3)
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2. Transaction Date (Month/Day/Year)
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2A. Deemed Execution Date, if any (Month/Day/Year)
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3. Transaction Code (Instr. 8)
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4. Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)
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7. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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Amount
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(A) or (D)
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Price
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Common Stock | 01/29/2021 |
| C |
| 1,641,252 | A | (1) | 1,641,252 | D |
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Common Stock | 01/29/2021 |
| C |
| 570,870 | A | (1) | 570,870 | I | By spouse. |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | |
| 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 control number. | SEC 1474 (9-02) |
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)
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2. Conversion or Exercise Price of Derivative Security
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3. Transaction Date (Month/Day/Year)
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3A. Deemed Execution Date, if any (Month/Day/Year)
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4. Transaction Code (Instr. 8)
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5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4, and 5)
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6. Date Exercisable and Expiration Date (Month/Day/Year)
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7. Title and Amount of Underlying Securities (Instr. 3 and 4)
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8. Price of Derivative Security (Instr. 5)
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9. Number of Derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4)
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10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4)
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11. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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(A)
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(D)
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Date Exercisable
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Expiration Date
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Title
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Amount or Number of Shares
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Series A Convertible Voting Preferred Stock | (1) (2) | 01/29/2021 |
| C |
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| 161,000 |
(1) |
(2) | Common Stock | 1,641,252 | (1) |
0
| D |
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Series A Convertible Voting Preferred Stock | (1) (2) | 01/29/2021 |
| C |
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| 56,000 |
(1) |
(2) | Common Stock | 570,870 | (1) |
0
| I | By spouse |
Reporting Owners
Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Steinmetz Nicole Franziska 1537 SOUTH NOVATO BLVD., #5 NOVATO, CA 94947 |
X
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X
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Acting CSO |
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Signatures
/s/ Paul Lytle, as attorney-in-fact for Nicole Steinmetz | |
01/29/2021 |
**Signature of Reporting Person | Date |
Explanation of Responses:
* | 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). |
(1) | Each share of the Series A Convertible Voting Preferred Stock automatically converted for no additional consideration into 10.194106 shares of common stock on January 29, 2021, the date that both of the following criteria were met: (i) upon the Registrant having a sufficient number of authorized and unissued shares of common stock so as to permit the conversion of all outstanding shares of the Series A Convertible Voting Preferred Stock into common stock, which occurred on December 2, 2020 in conjunction with the reverse stock split; and (ii) the effectiveness of any registration statement registering the resale of the underlying shares of common stock of the Registrant, which occurred on January 29, 2021. |
(2) | The Series A Convertible Voting Preferred Stock has no expiration date. |
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure.
Potential persons who are to respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB number.
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