0000899243-17-001245.txt : 20170113 0000899243-17-001245.hdr.sgml : 20170113 20170113145402 ACCESSION NUMBER: 0000899243-17-001245 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20161117 FILED AS OF DATE: 20170113 DATE AS OF CHANGE: 20170113 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Fuse Medical, Inc. CENTRAL INDEX KEY: 0000319016 STANDARD INDUSTRIAL CLASSIFICATION: WHOLESALE-MEDICAL, DENTAL & HOSPITAL EQUIPMENT & SUPPLIES [5047] IRS NUMBER: 591224913 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 1300 SUMMIT AVE STREET 2: SUITE 670 CITY: FORT WORTH STATE: TX ZIP: 76102 BUSINESS PHONE: 817-439-7025 MAIL ADDRESS: STREET 1: 1300 SUMMIT AVE STREET 2: SUITE 670 CITY: FORT WORTH STATE: TX ZIP: 76102 FORMER COMPANY: FORMER CONFORMED NAME: GOLF ROUNDS COM INC DATE OF NAME CHANGE: 19991126 FORMER COMPANY: FORMER CONFORMED NAME: AMERICAN METALS SERVICE INC DATE OF NAME CHANGE: 19920703 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: NC 143 Family Holdings GP LLC CENTRAL INDEX KEY: 0001693757 STATE OF INCORPORATION: TX FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 000-10093 FILM NUMBER: 17527559 BUSINESS ADDRESS: STREET 1: 1565 NORTH CENTRAL EXPRESSWAY, SUITE 200 CITY: RICHARDSON STATE: TX ZIP: 75080 BUSINESS PHONE: 2142899914 MAIL ADDRESS: STREET 1: 1565 NORTH CENTRAL EXPRESSWAY, SUITE 200 CITY: RICHARDSON STATE: TX ZIP: 75080 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Medtech Family Trust CENTRAL INDEX KEY: 0001693760 STATE OF INCORPORATION: TX FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 000-10093 FILM NUMBER: 17527560 BUSINESS ADDRESS: STREET 1: 1565 NORTH CENTRAL EXPRESSWAY, SUITE 200 CITY: RICHARDSON STATE: TX ZIP: 75080 BUSINESS PHONE: 2142899914 MAIL ADDRESS: STREET 1: 1565 NORTH CENTRAL EXPRESSWAY, SUITE 200 CITY: RICHARDSON STATE: TX ZIP: 75080 3 1 doc3.xml FORM 3 SUBMISSION X0206 3 2016-11-17 0 0000319016 Fuse Medical, Inc. FZMD 0001693760 Medtech Family Trust 1565 NORTH CENTRAL EXPWY, SUITE 200 RICHARDSON TX 75080 0 0 1 0 0001693757 NC 143 Family Holdings GP LLC 1565 NORTH CENTRAL EXPWY, SUITE 200 RICHARDSON TX 75080 0 0 1 0 Amended and Restated Promissory Note 0.08 2017-01-16 Common Stock 656678 I See Footnote Promissory Note 0.08 2017-01-16 Common Stock 640239 I See Footnote The Amended and Restated Promissory Note, dated October 19, 2016, made by the Issuer and payable to the order of NC 143 Family Holdings, LP, a Texas limited partnership ("NC 143"), in the principal amount of $50,000 ("NC 143 #1") became payable upon demand on December 19, 2016 and will be convertible into shares of common stock of the Issuer on or after January 16, 2017. NC 143 Note #1 does not provide for a stated expiration date. On or after January 16, 2017, NC 143 will have the right to convert all or any portion of the then unpaid principal and interest balance of NC 143 Note #1 into shares of common stock of the Issuer at a conversion price of $0.08 per share. The number of shares reported in box 3 is based on the application of such conversion rate to the amount of principal and interest that will be outstanding on January 16, 2017, if NC 143 Note #1 remains outstanding on such date. These securities are directly owned by NC 143. Mark W. Brooks is the sole trustee of Medtech Family Trust dated October 1, 2014 ("Medtech"); Medtech is the sole manager of NC 143 Family Holdings GP LLC (the "GP"); and the GP is the sole general partner of NC 143. Accordingly, each of Mark W. Brooks, Medtech and the GP indirectly beneficially owns the reported securities. This Form 3 is filed by Medtech and the GP. NC 143 and Mark W. Brooks previously jointly filed a Form 3 reporting their beneficial ownership of these securities. The Promissory Note, dated October 19, 2016, made by the Issuer and payable to the order of NC 143 in the principal amount of $50,000 ("NC 143 Note #2") became payable upon demand on December 19, 2016 and will be convertible into shares of common stock of the Issuer on or after January 16, 2017. NC 143 Note #2 does not provide for a stated expiration date. On or after January 16, 2017, NC 143 will have the right to convert all or any portion of the then unpaid principal and interest balance of NC 143 Note #2 into shares of common stock of the Issuer at a conversion price of $0.08 per share. The number of shares reported in box 3 is based on the application of such conversion rate to the amount of principal and interest that will be outstanding on January 16, 2017, if NC 143 Note #2 remains outstanding on such date. /s/ Mark W. Brooks, Trustee of Medtech Family Trust, sole manager of NC 143 Family Holdings GP LLC 2017-01-13