0001213900-21-058626.txt : 20211112 0001213900-21-058626.hdr.sgml : 20211112 20211112153830 ACCESSION NUMBER: 0001213900-21-058626 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20211110 FILED AS OF DATE: 20211112 DATE AS OF CHANGE: 20211112 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Vajdic Branislav CENTRAL INDEX KEY: 0001422425 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-41060 FILM NUMBER: 211403007 MAIL ADDRESS: STREET 1: 2033 GATEWAY PLAZA, SUITE 500 CITY: SAN JOSE STATE: CA ZIP: 95110 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: HeartBeam, Inc. CENTRAL INDEX KEY: 0001779372 STANDARD INDUSTRIAL CLASSIFICATION: SURGICAL & MEDICAL INSTRUMENTS & APPARATUS [3841] IRS NUMBER: 474881450 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 2118 WALSH AVE., SUITE 210 CITY: SANTA CLARA STATE: CA ZIP: 95050 BUSINESS PHONE: 408-899-4443 MAIL ADDRESS: STREET 1: 2118 WALSH AVE., SUITE 210 CITY: SANTA CLARA STATE: CA ZIP: 95050 3 1 ownership.xml X0206 3 2021-11-10 0 0001779372 HeartBeam, Inc. BEAT 0001422425 Vajdic Branislav 2118 WALSH AVE, SUITE 210 SANTA CLARA CA 95050 0 1 1 0 Chief Executive Officer Common Stock 794545 D Convertible Promissory Note Common Stock 115559 D Common Stock warrant (right to buy) 2.75 2023-02-11 Common Stock 5818 D Common Stock warrant (right to buy) 0.0003 2023-02-12 Common Stock 363636 D 32,727 shares are held in the name of his spouse, Marijana Rakic. Represents $485,347.80 of outstanding principal and interest calculated through November 10, 2021. The note will convert into 115,559 shares of Common Stock upon the closing of the Issuer's initial public offering of Common Stock (the "IPO"). All of the shares subject to the warrant are fully vested and exercisable as of the date hereof. The shares subject to the warrant are exercisable upon the earliest to occur of several events, including the closing of the IPO and the Issuer having a market capitalization of at least $50,000,000 for five consecutive business days. /s/ Branislav Vajdic 2021-11-10