SEC Form 3
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*
BAXTER INTERNATIONAL INC

(Last) (First) (Middle)
ONE BAXTER PARKWAY

(Street)
DEERFIELD IL 60015

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
06/23/2021
3. Issuer Name and Ticker or Trading Symbol
Miromatrix Medical Inc. [ MIRO ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director X 10% Owner
Officer (give title below) Other (specify below)
5. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
Form filed by One Reporting Person
X Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Beneficially Owned
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)
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 C Convertible Preferred Stock (1) (1) Common Stock 2,343,750 (1) I By Baxter Healthcare Corporation(2)
1. Name and Address of Reporting Person*
BAXTER INTERNATIONAL INC

(Last) (First) (Middle)
ONE BAXTER PARKWAY

(Street)
DEERFIELD IL 60015

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
Director X 10% Owner
Officer (give title below) Other (specify below)
1. Name and Address of Reporting Person*
BAXTER HEALTHCARE CORP

(Last) (First) (Middle)
ONE BAXTER PARKWAY

(Street)
DEERFIELD IL 60015

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
Director X 10% Owner
Officer (give title below) Other (specify below)
Explanation of Responses:
1. The Series C Convertible Preferred Stock is convertible into the number of shares of the Issuer's common stock shown in column 3 and have no expiration date. The Series C Convertible Preferred Stock will automatically convert into common stock upon the closing of the Issuer's initial public offering.
2. The reported securities are owned directly by Baxter Healthcare Corporation, a wholly owned subsidiary of Baxter International Inc.
Remarks:
/s/ Ellen K. Bradford, Senior Vice President & Corporate Secretary 06/23/2021
/s/ Ellen K. Bradford, Vice President & Secretary 06/23/2021
** 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.
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