0000897069-23-001091.txt : 20230804 0000897069-23-001091.hdr.sgml : 20230804 20230804134239 ACCESSION NUMBER: 0000897069-23-001091 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20230802 FILED AS OF DATE: 20230804 DATE AS OF CHANGE: 20230804 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Cappy George CENTRAL INDEX KEY: 0001986372 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-41765 FILM NUMBER: 231143271 MAIL ADDRESS: STREET 1: C/O MIRA PHARMACEUTICALS, INC. STREET 2: 900 WEST PLATT STREET, SUITE 200 CITY: TAMPA STATE: FL ZIP: 33606-2173 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Bay Shore Trust CENTRAL INDEX KEY: 0001986593 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-41765 FILM NUMBER: 231143270 BUSINESS ADDRESS: STREET 1: C/O MIRA PHARMACEUTICALS, INC. STREET 2: 900 WEST PLATT STREET, SUITE 200 CITY: TAMPA STATE: FL ZIP: 33606-2173 BUSINESS PHONE: (737) 289-0835 MAIL ADDRESS: STREET 1: C/O MIRA PHARMACEUTICALS, INC. STREET 2: 900 WEST PLATT STREET, SUITE 200 CITY: TAMPA STATE: FL ZIP: 33606-2173 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: MIRA PHARMACEUTICALS, INC. CENTRAL INDEX KEY: 0001904286 STANDARD INDUSTRIAL CLASSIFICATION: PHARMACEUTICAL PREPARATIONS [2834] IRS NUMBER: 853354547 STATE OF INCORPORATION: FL BUSINESS ADDRESS: STREET 1: 855 N WOLFE STREET #623-6 CITY: BALTIMORE STATE: MD ZIP: 21205 BUSINESS PHONE: 813-369-5150 MAIL ADDRESS: STREET 1: 324 SOUTH HYDE PARK AVENUE, SUITE 350 CITY: TAMPA STATE: FL ZIP: 33606 FORMER COMPANY: FORMER CONFORMED NAME: Mira1a Therapeutics, Inc. DATE OF NAME CHANGE: 20220112 4 1 form4.xml X0508 4 2023-08-02 0001904286 MIRA PHARMACEUTICALS, INC. MIRA 0001986372 Cappy George C/O MIRA PHARMACEUTICALS, INC. 900 WEST PLATT STREET, SUITE 200 TAMPA FL 33606-2173 true 0001986593 Bay Shore Trust C/O MIRA PHARMACEUTICALS, INC. 900 WEST PLATT STREET, SUITE 200 TAMPA FL 33606-2173 true false Common Stock 2023-08-02 4 P 0 157170 7 A 2740270 I By Trust Common Stock 20000 D Common Stock Warrant (right to buy) 5 2023-04-28 2028-04-28 Common Stock 1000000 1000000 I By Trust Represents the acquisition of shares of common stock by the Bay Shore Trust (the "Trust") through the conversion of an aggregate of $1,100,190 of indebtedness owing by the Issuer to the Trust, with such conversion occurring on the date of the Issuer's initial public offering at a conversion price of $7.00 per share. These securities are owned directly by the Trust, a greater-than-10% owner of the Issuer. As sole trustee of the Trust, George Cappy ("Mr. Cappy") has sole ownership and dispositive power over these securities and is therefore deemed to be an indirect beneficial owner of the securities for purposes of SEC Rule 13d-3, although Mr. Cappy disclaims beneficial ownership of the reported securities due to the absence of any pecuniary interest therein. These securities are owned directly by Mr. Cappy. /s/ Michelle Yanez, Attorney-in-Fact for George Cappy 2023-08-04 /s/ Michelle Yanez, Attorney-in-Fact for George Cappy, Trustee 2023-08-04