Initial Statement of Beneficial Ownership (3)
30 June 2021 - 7:18AM
Edgar (US Regulatory)
FORM 3
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0104
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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
*
Adjemian Kevork Tro |
2. Date of Event Requiring Statement (MM/DD/YYYY)
6/25/2021
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3. Issuer Name and Ticker or Trading Symbol
Electric Last Mile Solutions, Inc. [ELMS]
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(Last)
(First)
(Middle)
1055 W SQUARE LAKE ROAD |
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director _____ 10% Owner ___X___ Officer (give title below) _____ Other (specify below) Chief Technical Officer / |
(Street)
TROY, MI 48098
(City)
(State)
(Zip)
| 5. If Amendment, Date Original Filed(MM/DD/YYYY)
| 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 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) |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security (Instr. 4) | 2. Date Exercisable and Expiration Date (MM/DD/YYYY) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form of Derivative Security: 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 |
Convertible Note | (1) | (1) | Common Stock | 55044 | (1) | I | by KA Trust (2) |
Explanation of Responses: |
(1) | On December 10, 2020, Electric Last Mile, Inc. ("ELM") entered into a $500,000 Convertible Note with KA Trust. The reporting person is the beneficial owner of the Convertible Note issued to KA Trust. Pursuant to the terms of the Convertible Note, upon the closing of the transaction contemplated pursuant to the Agreement and Plan of Merger, dated as of December 10, 2020, by and among Forum Merger III Corporation ("Forum") (upon consummation of the business combination, the surviving "Issuer" is renamed "Electric Last Mile Solutions, Inc."), ELMS Merger Corp., a wholly owned subsidiary of Forum, and ELM, as amended, the Convertible Note will be converted into shares of common stock of Electric Last Mile Solutions, Inc. |
(2) | The reporting person has sole voting and investment power with respect to the shares of common stock held by the KA Trust. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Adjemian Kevork Tro 1055 W SQUARE LAKE ROAD TROY, MI 48098 |
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| Chief Technical Officer |
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Signatures
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/s/ Benjamin Wu, attorney-in-fact for Kevork Tro Adjemian | | 6/29/2021 |
**Signature of Reporting Person | Date |
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