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) 06/28/2005 |
3. Issuer Name and Ticker or Trading Symbol
HEMOSENSE INC [ HEM ] |
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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) 06/13/2005 |
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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) |
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 | ||||
Common Stock Warrant (right to buy) | (1) | 04/25/2010 | Common Stock | 5,417(2)(3) | $5.5(2)(4) | D |
Explanation of Responses: |
1. Immediately. |
2. Calculated based on an assumed exercise price of $5.50 per share. The number of shares issuable upon the exercise of this warrant may be calculated by dividing $29,798 by the exercise price per share. The exercise price will be set at the price per share paid by the investors in the issuer's initial public offering. |
3. On June 13, 2005, the reporting person mistakenly filed a Form 3 reporting a warrant for 3,310 shares of common stock. As of June 28, 2005, the reporting person owned a warrant for 5,417 shares. |
4. On June 13, 2005, the reporting person mistakenly filed a Form 3 reporting a conversion price of $9.00. As of June 28, 2005, the conversion price is $5.50. |
Remarks: |
This report is being amended to change the Date of Event Requiring Statement to June 28, 2005, the effective date of the issuer's Registration Statement on Form S-1 (the "Effective Date"). |
/s/ Stephen R. Halpin, Jr., Trustee | 06/28/2005 | |
** 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. |