0000899243-21-048904.txt : 20211217 0000899243-21-048904.hdr.sgml : 20211217 20211217204319 ACCESSION NUMBER: 0000899243-21-048904 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20211215 FILED AS OF DATE: 20211217 DATE AS OF CHANGE: 20211217 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Appelbaum Kevin J CENTRAL INDEX KEY: 0001547557 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39864 FILM NUMBER: 211503411 MAIL ADDRESS: STREET 1: 4160 DUBLIN BLVD., SUITE 200 CITY: DUBLIN STATE: CA ZIP: 94568 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Kevin Appelbaum, or his successor(s), as Trustee of the Kevin Appelbaum Revocable Trust under Revocable Trust Declaration dated 5/16/2020, as amended CENTRAL INDEX KEY: 0001890904 STATE OF INCORPORATION: OR FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39864 FILM NUMBER: 211503410 BUSINESS ADDRESS: STREET 1: 548 MARKET STREET, #49404 CITY: SAN FRANCISCO STATE: CA ZIP: 94104 BUSINESS PHONE: 415.887.2311 MAIL ADDRESS: STREET 1: 548 MARKET STREET, #49404 CITY: SAN FRANCISCO STATE: CA ZIP: 94104 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Better Therapeutics, Inc. CENTRAL INDEX KEY: 0001832415 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-HEALTH SERVICES [8000] IRS NUMBER: 000000000 STATE OF INCORPORATION: DE FISCAL YEAR END: 1028 BUSINESS ADDRESS: STREET 1: 311 WEST 43RD STREET, 12TH FLOOR CITY: NEW YORK STATE: NY ZIP: 10036 BUSINESS PHONE: 646-493-6558 MAIL ADDRESS: STREET 1: 311 WEST 43RD STREET, 12TH FLOOR CITY: NEW YORK STATE: NY ZIP: 10036 FORMER COMPANY: FORMER CONFORMED NAME: Mountain Crest Acquisition Corp II DATE OF NAME CHANGE: 20201116 4 1 doc4.xml FORM 4 SUBMISSION X0306 4 2021-12-15 0 0001832415 Better Therapeutics, Inc. BTTX 0001547557 Appelbaum Kevin J C/O BETTER THERAPEUTICS, INC. 548 MARKET STREET, #49404 SAN FRANCISCO CA 94104 1 1 1 0 Chief Executive Officer 0001890904 Kevin Appelbaum, or his successor(s), as Trustee of the Kevin Appelbaum Revocable Trust under Revocable Trust Declaration dated 5/16/2020, as amended C/O BETTER THERAPEUTICS, INC. 548 MARKET STREET, #49404 SAN FRANCISCO CA 94104 0 0 1 0 Common Stock 2021-12-15 4 P 0 750 4.7065 A 2750 D Common Stock 2406719 I By Trust These shares are owned directly by Kevin Appelbaum, or his successor(s), as Trustee of the Kevin Appelbaum Revocable Trust under Revocable Trust Declaration dated May 16, 2020, as amended (the "Trust"), and indirectly by Mr. Appelbaum as trustee of the Trust. Mr. Appelbaum is an officer, director and ten percent owner of Issuer. /s/ Mark Heinen, Attorney-in-Fact for Kevin J. Appelbaum 2021-12-17 /s/ Mark Heinen, Attorney-in-Fact for Kevin Appelbaum, or his successor(s), as Trustee of the Kevin Appelbaum Revocable Trust under Revocable Trust Declaration dated May 16, 2020, as amended 2021-12-17