0001171843-15-005039.txt : 20150904 0001171843-15-005039.hdr.sgml : 20150904 20150904170658 ACCESSION NUMBER: 0001171843-15-005039 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20150902 FILED AS OF DATE: 20150904 DATE AS OF CHANGE: 20150904 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: American CareSource Holdings, Inc. CENTRAL INDEX KEY: 0001316645 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-MISC HEALTH & ALLIED SERVICES, NEC [8090] IRS NUMBER: 200428568 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 1170 PEACHTREE STREET, NE STREET 2: SUITE 2350 CITY: ATLANTA STATE: GA ZIP: 30309 BUSINESS PHONE: 972-308-6830 MAIL ADDRESS: STREET 1: 1170 PEACHTREE STREET, NE STREET 2: SUITE 2350 CITY: ATLANTA STATE: GA ZIP: 30309 FORMER COMPANY: FORMER CONFORMED NAME: American Caresource Holdings, Inc. DATE OF NAME CHANGE: 20050615 FORMER COMPANY: FORMER CONFORMED NAME: American Caresouce Holdings, Inc. DATE OF NAME CHANGE: 20050204 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: PAPPAJOHN JOHN CENTRAL INDEX KEY: 0000897464 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-33094 FILM NUMBER: 151095003 MAIL ADDRESS: STREET 1: 1660 WALT WHITMAN ROAD STREET 2: SUITE 105 CITY: MELVILLE STATE: NY ZIP: 11747 4 1 formfour.xml X0306 4 2015-09-02 0 0001316645 American CareSource Holdings, Inc. ANCI 0000897464 PAPPAJOHN JOHN C/O AMERICAN CARESOURCE HOLDINGS, INC. 1170 PEACHTREE STREET NE, SUITE 2350 ATLANTA GA 30309 1 1 0 0 Acting Chief Executive Officer Warrant to Purchase Common Stock, par value $0.01 per share 1.70 2015-09-02 4 A 0 150000 A 2020-08-12 Common Stock 150000 150000 D Warrants are exercisable immediately. Issued in consideration for providing a guarantee to a lender of up to $500,000 for an extension to an existing line of credit rendered to the company. /s/ John Pappajohn 2015-09-04