0001171843-15-006768.txt : 20151211 0001171843-15-006768.hdr.sgml : 20151211 20151211141124 ACCESSION NUMBER: 0001171843-15-006768 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20151209 FILED AS OF DATE: 20151211 DATE AS OF CHANGE: 20151211 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: 151282887 MAIL ADDRESS: STREET 1: 1660 WALT WHITMAN ROAD STREET 2: SUITE 105 CITY: MELVILLE STATE: NY ZIP: 11747 4 1 formfour.xml X0306 4 2015-12-09 0 0001316645 American CareSource Holdings, Inc. GNOW 0000897464 PAPPAJOHN JOHN C/O AMERICAN CARESOURCE HOLDINGS, INC. 1170 PEACHTREE STREET NE, SUITE 2350 ATLANTA GA 30309 1 1 1 0 Acting Chief Executive Officer Common Stock, par value $0.01 per share 2015-12-09 4 A 0 2857142 A 5166760 D Common Stock, par value $0.01 per share 16791 I By Equity Dynamics, Inc. Common Stock, par value $0.01 per share 5000 I By Halkis, Ltd. Common Stock, par value $0.01 per share 5000 I By Spouse Common Stock, par value $0.01 per share 5000 I By Thebes, Ltd. Warrant to Purchase Common Stock 0.875 2015-12-09 4 A 0 2857142 A 2015-12-09 2020-12-09 Common Stock 2857142 2857142 D In connection with a public offering (the "Offering") of American CareSource Holdings, Inc. (the "Issuer"), the Reporting Person acquired 2,857,142 Class A Units (the "Units") for $0.70 per Unit, with each such Unit consisting of one share of the Issuer's common stock, par value $0.01 per share (the "Common Stock"), and a warrant to purchase one share of Common Stock with an exercise price of $0.875 (the "Warrant"). Accordingly, the Reporting Person acquired 2,857,142 shares of Common Stock and a Warrant to purchase 2,857,142 shares of Common Stock in the Offering. The Reporting Person disclaims beneficial ownership of these securities, and this report shall not be deemed an admission that the reporting person is the beneficial owner of the securities for purposes of Section 16 or for any other purpose. /s/ John Pappajohn 2015-12-11