Initial Statement of Beneficial Ownership (3)
20 Enero 2022 - 5:07PM
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
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Zygmont Chester Stanley III |
2. Date of Event Requiring Statement (MM/DD/YYYY)
1/10/2022
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3. Issuer Name and Ticker or Trading Symbol
REVELATION BIOSCIENCES, INC. [REVB]
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(Last)
(First)
(Middle)
C/O REVELATION BIOSCIENCES, INC., 4660 LA JOLLA VILLAGE DR., SUITE 100 |
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director _____ 10% Owner ___X___ Officer (give title below) _____ Other (specify below) Chief Financial Officer / |
(Street)
SAN DIEGO, CA 92122
(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) |
Common Stock | 463285 | I | By Trust (1) |
Common Stock | 218017 | I | By LLC (2) |
Common Stock | 2144 | I | By Spouse (3) |
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 |
Restricted Stock Unit | (4) | (5) | Common Stock | 6853 | (6) | D | |
Restricted Stock Unit | (7) | (5) | Common Stock | 15588 | (6) | D | |
Explanation of Responses: |
(1) | Shares are held by The Zygmont Family Trust Dated October 25, 2016, with respect to which Chester S Zygmont III is a trustee. |
(2) | Shares are held by Czeslaw Capital Fund, LLC. Chester S Zygmont III is the sole manager of Czeslaw Capital Fund, LLC. |
(3) | The Reporting Person disclaims beneficial ownership of shares held by the Reporting Person's spouse directly. |
(4) | These RSUs vest 25% on January 31, 2021, and thereafter quarterly over a three-year period. |
(5) | RSUs do not expire; they either vest or are canceled prior to vesting date. |
(6) | Each RSU converts into common stock on a one-for-one basis. |
(7) | These RSUs vest 25% on February 23, 2022, and thereafter monthly over a three-year period. |
Remarks: Exhibit 24 - Power of Attorney. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Zygmont Chester Stanley III C/O REVELATION BIOSCIENCES, INC. 4660 LA JOLLA VILLAGE DR., SUITE 100 SAN DIEGO, CA 92122 |
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| Chief Financial Officer |
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Signatures
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/s/ J.P. Galda, as attorney-in-fact for Chester S Zygmont, III | | 1/20/2022 |
**Signature of Reporting Person | Date |
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