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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940 |
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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) |
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 Underlying Securities (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 of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
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Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||||||
18% Convertible Promissory Note | $ 0.2 | 06/29/2012 | C | $ 150,000 (1) | 11/29/2011 | (3) | Common Stock | $ 150,000 | $ 0 | 0 | D |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Hariri Robert J C/O MYOS CORPORATION 45 HORSEHILL ROAD, SUITE 106 CEDAR KNOLLS, NJ 07927 |
X | X |
/s/ Robert Hariri | 07/02/2012 | |
**Signature of Reporting Person | Date |
* | 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) | Reflects the conversion of the 18% Convertible Promissory Note in the amount of $150,000 (including accrued interest) issued to the reporting person in November 2011 into shares of common stock at a conversion price of $0.20 per share. |
(2) | Reflects the exchange of outstanding debt in the amount of $99,500 (including accrued interest) due to the reporting person for shares of common stock at a conversion price equal to $0.20 per share. |
(3) | The 18% Convertible Promissory Note is due at the earlier of (i) May 29, 2012 and (ii) the consummation by the Company of a debt or equity financing in excess of $2,000,000. |