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