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