0001104659-22-107039.txt : 20221007 0001104659-22-107039.hdr.sgml : 20221007 20221007132911 ACCESSION NUMBER: 0001104659-22-107039 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20220607 FILED AS OF DATE: 20221007 DATE AS OF CHANGE: 20221007 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Van Sam CENTRAL INDEX KEY: 0001937248 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-41414 FILM NUMBER: 221300193 MAIL ADDRESS: STREET 1: 1500 LAKEVIEW LOOP CITY: ANAHEIM STATE: CA ZIP: 92807 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: PHOENIX MOTOR INC. CENTRAL INDEX KEY: 0001879848 STANDARD INDUSTRIAL CLASSIFICATION: TRUCK & BUS BODIES [3713] IRS NUMBER: 000000000 STATE OF INCORPORATION: DE BUSINESS ADDRESS: STREET 1: 401 SOUTH DOUBLEDAY AVENUE CITY: ONTARIO STATE: CA ZIP: 91761 BUSINESS PHONE: 909-987-0815 MAIL ADDRESS: STREET 1: 401 SOUTH DOUBLEDAY AVENUE CITY: ONTARIO STATE: CA ZIP: 91761 3 1 tm2227762-10_3seq1.xml OWNERSHIP DOCUMENT X0206 3 2022-06-07 0 0001879848 PHOENIX MOTOR INC. PEV 0001937248 Van Sam 1500 LAKEVIEW LOOP ANAHEIM CA 92807 1 0 0 0 Options 0.04 2022-06-30 2032-06-07 Common Stock 3750 D Represents shares of common stock underlying options that vest quarterly-annually and are exercisable at $0.04 per share of common stock for a period ending June 2032. /s/ Sam Van 2022-10-06