SEC Form 4
FORM 4 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934
or Section 30(h) of the Investment Company Act of 1940
OMB APPROVAL
OMB Number: 3235-0287
Estimated average burden
hours per response: 0.5
  
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
1. Name and Address of Reporting Person*
STERN THEODORE

(Last) (First) (Middle)
220 N. BELLEFIELD AVE., UNIT 1101

(Street)
PITTSBURGH, PA 15213

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
Ipsidy Inc. [ IDTY ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director 10% Owner
Officer (give title below) Other (specify below)
3. Date of Earliest Transaction (Month/Day/Year)
05/05/2021
4. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security (Instr. 3) 2. Transaction Date (Month/Day/Year) 2A. Deemed Execution Date, if any (Month/Day/Year) 3. Transaction Code (Instr. 8) 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 7. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V Amount (A) or (D) Price
Common Stock, $0.0001 par value per share 5,885,445 D
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 3) 2. Conversion or Exercise Price of Derivative Security 3. Transaction Date (Month/Day/Year) 3A. Deemed Execution Date, if any (Month/Day/Year) 4. Transaction Code (Instr. 8) 5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) 6. Date Exercisable and Expiration Date (Month/Day/Year) 7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4) 8. Price of Derivative Security (Instr. 5) 9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) 10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 11. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V (A) (D) Date Exercisable Expiration Date Title Amount or Number of Shares
Stock Options(3) $0.24 05/05/2021 A 1,645,521 05/05/2021 05/05/2031 Common Stock, $0.0001 par value per share 1,645,521 $0 1,645,521 D
Common Stock Purchase Warrant $0.15 06/30/2020 06/30/2022 Common Stock, $0.0001 par value per share 250,000 250,000 D
Amended and Restated Promissory Notes $0.2 02/14/2020 02/28/2022 Common Stock, $0.0001 par value per share 15,000,000 15,000,000 I See footnote(1)
15% Convertible Note $0.2 02/14/2020 02/28/2022 Common Stock, $0.0001 par value per share 375,000 375,000 D
Interest Shares $0.2 01/31/2017 (2) Common Stock, $0.0001 par value per share 3,310,000 3,310,000 I See Footnote(2)
Explanation of Responses:
1. Represents 15,000,000 shares of common stock that may be issued upon the conversion of principal at $0.20 per share under that certain Amended & Restated Secured Promissory Note in the principal amount as of the date hereof $2,000,000 issued to the Theodore Stern Revocable Trust (the "Trust").
2. Represents 3,310,000 shares of common stock that may be issued upon the conversion of interest accrued at $0.20 per share under that certain Unsecured Promissory Note in the principal amount as of the date hereof $2,000,000 issued to the Trust.
3. On May 5, 2021, the Company granted Mr. Stern a Non-Statutory Option to acquire 1,645,521 shares of common stock at an exercise price of $0.24 per share with 973,880 shares vesting upon grant of Non-Statutory Option and 671,641 shares of common stock underlying the stock options vesting over twelve months.
/s/ Theodore Stern 05/07/2021
** 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 4 (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.