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) 06/30/2016 |
3. Issuer Name and Ticker or Trading Symbol
UNIVERSAL BIOSENSORS INC [ UBI ] |
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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, par value US$0.0001(1) | 25,172,665 | I | By partnership(2)(3) |
Common stock, par value US$0.0001(1) | 220,000 | I | By the Coleman Super Fund(4) |
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 |
Explanation of Responses: |
1. Traded as CHESS Depositary Interests ("CDIs") on the Australian Securities Exchange. CDIs represent beneficial interests in the common stock held by CHESS Depositary Nominees Pty Ltd. |
2. The Reporting Person is a director of Viburnum Funds Pty Ltd ("Viburnum"), which is the sole trustee and manager of each of VF Strategic Equities Fund ("Strategic Fund"), VF High Conviction Fund ("Conviction Fund") and VF Australian Equities Fund ("Australian Fund"), the direct beneficial owners of the common stock. The Reporting Person disclaims beneficial ownership within the meaning of Section 16 of the Securities Exchange Act of 1934, as amended, or otherwise of the common stock held by Strategic Fund, Conviction Fund and Australian Fund, except to the extent of his pecuniary interest therein. |
3. Viburnum, as the sole trustee and manager of Strategic Fund, Conviction Fund and Australian Fund, may be deemed to beneficially own 25,172,665 shares of common stock, which consist of 17,420,000, 7,597,929 and 154,736 shares of common stock held by Strategic Fund, Conviction Fund and Australian Fund, respectively. Viburnum, as the sole trustee and manager of each of Strategic Fund, Conviction Fund and Australian Fund, shares voting and dispositive power over, and may be deemed to beneficially own, the common stock held by the foregoing entities. The Reporting Person shares voting and dispositive power over, and may be deemed to beneficially own, the common stock held by the foregoing entities due to the Reporting Person serving as a director of Viburnum. |
4. Craig E. and Phylis Coleman are the trustees of the Coleman Super Fund, of which Mr. Coleman is a potential beneficiary |
Remarks: |
Exhibit 24.1 - Power of Attorney |
/s/ David St. Quintin, as attorney-in-fact | 07/11/2016 | |
** 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. |