Statement of Changes in Beneficial Ownership (4)
10 January 2019 - 6:16AM
Edgar (US Regulatory)
FORM 4
[ ]
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b).
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0287
Estimated average burden
hours per response...
0.5
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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
*
Rosellini William
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2. Issuer Name
and
Ticker or Trading Symbol
NEXEON MEDSYSTEMS INC
[
NXNN
]
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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
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(Last)
(First)
(Middle)
C/O NEXEON MEDSYSTEMS INC, 1910 PACIFIC AVENUE, SUITE 20000
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3. Date of Earliest Transaction
(MM/DD/YYYY)
1/8/2019
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(Street)
DALLAS, TX 75201
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
___ Form filed by One Reporting Person
_
X
_ 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. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. 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
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1/8/2019
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G
(1)
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26500
(1)
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D
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(1)
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644527
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I
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Held by Rosellini Scientific Holdings, LLC
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Common Stock
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1/8/2019
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G
(1)
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19000
(1)
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D
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(1)
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625527
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I
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Held by Rosellini Scientific Holdings, LLC
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Common Stock
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1/8/2019
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G
(1)
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35000
(1)
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D
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(1)
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590527
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I
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Held by Rosellini Scientific Holdings, LLC
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Common Stock
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1/8/2019
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G
(1)
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402785
(1)
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D
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(1)
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187742
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I
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Held by Rosellini Scientific Holdings, LLC
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Table II - Derivative Securities Beneficially Owned (
e.g.
, puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 3)
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2. Conversion or Exercise Price of Derivative Security
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3. Trans. Date
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3A. Deemed Execution Date, if any
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4. Trans. 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
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7. Title and Amount of Securities Underlying Derivative Security
(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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Explanation of Responses:
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(1)
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On January 8, 2019, Rosellini Scientific Holdings, LLC respectively gifted 26,500 shares of common stock of the Issuer to Elizabeth Rosellini, 19,000 shares to Michael Rosellini, 35,000 shares to Rosellini Family Irrevocable Trust UA Dated 09/24/2018, and 402,785 shares to Rosellini Family Irrv Tr 2.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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Rosellini William
C/O NEXEON MEDSYSTEMS INC
1910 PACIFIC AVENUE, SUITE 20000
DALLAS, TX 75201
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X
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X
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CHIEF EXECUTIVE OFFICER
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Rosellini Scientific Holdings, LLC
CORNER OF JEWS AND MARION
CHARLESTON, U7
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X
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Signatures
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/s/ William Rosellini
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1/9/2019
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**
Signature of Reporting Person
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Date
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/s/ William Rosellini, Sole Member / Manager of Rosellini Scientific Holdings, LLC
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1/9/2019
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 4(b)(v).
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**
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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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Note:
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File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure.
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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.
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