0001615774-15-002580.txt : 20150916
0001615774-15-002580.hdr.sgml : 20150916
20150916171931
ACCESSION NUMBER: 0001615774-15-002580
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20150914
FILED AS OF DATE: 20150916
DATE AS OF CHANGE: 20150916
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: CNS RESPONSE, INC.
CENTRAL INDEX KEY: 0000822370
STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-MISC HEALTH & ALLIED SERVICES, NEC [8090]
IRS NUMBER: 870419387
STATE OF INCORPORATION: DE
FISCAL YEAR END: 0930
BUSINESS ADDRESS:
STREET 1: 85 ENTERPRISE
STREET 2: SUITE 410,
CITY: ALISO VIEJO
STATE: CA
ZIP: 92656
BUSINESS PHONE: (714) 545 3288
MAIL ADDRESS:
STREET 1: 85 ENTERPRISE
STREET 2: SUITE 410,
CITY: ALISO VIEJO
STATE: CA
ZIP: 92656
FORMER COMPANY:
FORMER CONFORMED NAME: STRATIVATION, INC.
DATE OF NAME CHANGE: 20051115
FORMER COMPANY:
FORMER CONFORMED NAME: SalesTactix, Inc.
DATE OF NAME CHANGE: 20040805
FORMER COMPANY:
FORMER CONFORMED NAME: AGE RESEARCH INC
DATE OF NAME CHANGE: 19990210
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Smith Robin L
CENTRAL INDEX KEY: 0001365035
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-35527
FILM NUMBER: 151110858
MAIL ADDRESS:
STREET 1: C/O PHASE III MEDICAL, INC.
STREET 2: 330 SOUTH SERVICE ROAD, SUITE 120
CITY: MELVILLE
STATE: NY
ZIP: 11747
4
1
s101833_form4.xml
OWNERSHIP DOCUMENT
X0306
4
2015-09-14
0
0000822370
CNS RESPONSE, INC.
CNSO
0001365035
Smith Robin L
C/O CNS RESPONSE, INC.
85 ENTERPRISE, SUITE 410
ALISO VIEJO
CA
92656
1
0
0
0
5% Secured Convertible Note due March 2016
0.05
2015-09-14
4
A
0
60000
0
A
2016-03-06
2016-03-21
Common Stock
1200000
60000
D
On September 14, 2015, the Issuer and the holders of the 5% Secured Convertible Notes due March 2016 (the "Notes") entered into an Omnibus Amendment to fix the conversion price of the Notes at $0.05 per share. The Omnibus Amendment amended the Notes and the September 22, 2014 Note Purchase Agreement, as amended, pursuant to which the Notes were issued.
The Notes are convertible into shares of common stock either: (i) voluntarily, beginning 15 days prior to the March 21, 2016 maturity date of the Notes (the "Maturity Date"), by the holder or (ii) automatically, if, prior to the Maturity Date, the Issuer consummates a Qualified Financing (as defined in the Notes).
The Maturity Date of the Notes is March 21, 2016.
The number of derivate securities beneficially owned does not include interest accrued at 5% per annum on the Notes.
/s/ Robin L. Smith
2015-09-16