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