0000899243-17-001246.txt : 20170113
0000899243-17-001246.hdr.sgml : 20170113
20170113145649
ACCESSION NUMBER: 0000899243-17-001246
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20161219
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: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 000-10093
FILM NUMBER: 17527573
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: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 000-10093
FILM NUMBER: 17527574
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
4
1
doc4.xml
FORM 4 SUBMISSION
X0306
4
2016-12-19
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
Common Stock
2016-12-19
4
P
0
5000000
0.08
A
5000000
I
See Footnote
These securities are directly owned by NC 143 Family Holdings, LP, a Texas limited partnership ("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 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 4 is filed by Medtech and the GP. NC 143 and Mark W. Brooks previously jointly filed a Form 4 reporting the acquisition of these securities.
/s/ Mark W. Brooks, Trustee of Medtech Family Trust, sole manager of NC 143 Family Holdings GP LLC
2017-01-13