FORM 3 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 INITIAL STATEMENT OF 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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1. Name and Address of Reporting Person*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 11/13/2012 |
3. Issuer Name and Ticker or Trading Symbol
ASSURED PHARMACY, INC. [ APHY ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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5. If Amendment, Date of Original Filed
(Month/Day/Year) |
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6. Individual or Joint/Group Filing (Check Applicable Line)
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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 | 65,000 | D(1) | |
Common Stock | 8,987 | I(1) | By IRA |
Common Stock | 96,036 | I(2) | By Pinewood Trading Fund, LP |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
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1. Title of Derivative Security (Instr. 4) | 2. Date Exercisable and Expiration Date (Month/Day/Year) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form: 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 | ||||
Series B Preferred Stock | (3) | (3) | Common Stock | 333,600 | $1.8 | I(2) | By Pinewood Trading Fund, LP |
Common Stock Warrants | 11/30/2011 | 11/30/2016 | Common Stock | 48,000 | $1.512 | I(2) | By Pinewood Trading Fund, LP |
16% Convertible Debentures | 11/30/2011 | 05/30/2014 | Common Stock | 40,000 | $1.26 | I(2) | By Pinewood Trading Fund, LP |
1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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Explanation of Responses: |
1. The reported securities are owned directly and indirectly by Jack E. Brooks. |
2. The reported securities are owned directly by Pinewood Trading Fund, L.P., and indirectly by Sagewood, LLC, as General Partner of Pinewood Trading Fund, L.P., and Jack E. Brooks, as Manager of Sagewood, LLC. Sagewood, LLC and Jack E. Brooks disclaim beneficial ownership of the reported securities except to the extent of their pecuniary interest therein. |
3. Series B Preferred Stock is convertible at any time at the reporting person's election, and has no expiration date. |
Remarks: |
Pinewood Trading Fund, LP, By Sagewood, LLC, General Partner, By Jack E. Brooks, Manager | 12/14/2012 | |
Sagewood, LLC, By Jack E. Brooks, Manager | 12/14/2012 | |
Jack E. Brooks | 12/14/2012 | |
** Signature of Reporting Person | Date | |
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | ||
* If the form is filed by more than one reporting person, see Instruction 5 (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). | ||
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. | ||
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 Number. |