FORM 4 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940 |
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). |
1. Name and Address of Reporting Person*
(Street)
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2. Issuer Name and Ticker or Trading Symbol
CNS RESPONSE, INC. [ CNSO ] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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3. Date of Earliest Transaction
(Month/Day/Year) 08/26/2009 | ||||||||||||||||||||||||||
4. If Amendment, Date of Original Filed
(Month/Day/Year) |
6. Individual or Joint/Group Filing (Check Applicable Line)
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned | ||||||||||
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1. Title of Security (Instr. 3) | 2. Transaction Date (Month/Day/Year) | 2A. Deemed Execution Date, if any (Month/Day/Year) | 3. Transaction Code (Instr. 8) | 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) | 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) | 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 7. Nature of Indirect Beneficial Ownership (Instr. 4) | |||
Code | V | Amount | (A) or (D) | Price | ||||||
Common Stock(1) | 08/26/2009 | C | 3,333,334 | A | (1) | 3,333,334 | D | |||
Common Stock | 08/26/2009 | P | 3,333,334 | A | $0.3 | 6,666,668 | D |
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||||||||||
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1. Title of Derivative Security (Instr. 3) | 2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) | 6. Date Exercisable and Expiration Date (Month/Day/Year) | 7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4) | 8. Price of Derivative Security (Instr. 5) | 9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) | 10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 11. Nature of Indirect Beneficial Ownership (Instr. 4) | ||||
Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||||||
Common Stock Warrants (Right to Buy)(1) | $0.3 | 08/26/2009 | C | 1,666,667 | 08/26/2009 | 08/26/2014 | Common Stock | 1,666,667 | $0 | 1,666,667 | D | ||||
Common Stock Warrants (Right to Buy)(2) | $0.3 | 08/26/2009 | P | 666,667 | 08/26/2009 | 08/26/2014 | Common Stock | 666,667 | $0 | 666,667 | D |
Explanation of Responses: |
1. On June 12, 2009, the Issuer issued to Mr. Pappajohn a Secured Convertible Promissory Note in the principal amount of $1,000,000. The note provided that in the event the Issuer consummates an equity financing transaction of at least $1,500,000 (excluding any and all notes and other liabilities or indebtedness which are converted) during the term of such note, then the outstanding principal amount on such note shall be automatically converted into the securities issued in the equity financing by dividing such amount by the per share price paid by the investors in such financing. On August 26, 2009, the Issuer raised approximately $2,000,000 in a private placement at a price of $0.30 per share, and Mr. Pappajohn was issued an aggregate of 3,333,334 shares of common stock and a five year non-callable warrant to purchase 1,666,667 shares of the Issuer's common stock at an exercise price of $0.30 per share pursuant to the terms of the note. |
2. Does not include Common Stock Warrant to purchase an aggregate of 1,000,000 shares of Common Stock gifted for no consideration at the time of issuance to certain relatives of Mr. Pappajohn for which he disclaims beneficial ownership. |
/s/ John Pappajohn | 08/31/2009 | |
** Signature of Reporting Person | Date | |
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | ||
* If the form is filed by more than one reporting person, see Instruction 4 (b)(v). | ||
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). | ||
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. | ||
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. |