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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES 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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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | |||
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 control number. | SEC 1474 (9-02) |
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 Underlying Securities (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 of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
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Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
LEVINE JACK C/O EZFILL HOLDINGS INC. 2125 BISCAYNE BLVD, #309 MIAMI, FL 33137 |
X |
/s/ Jack Levine | 12/06/2021 | |
**Signature of Reporting Person | Date |
* | 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). |
(1) | The 20,263 shares the Reporting Person purchased on December 2, 2021 are held by Jack Levine and Susan Levine JTWROS, a joint tenant account of the Reporting Person and his wife. |
(2) | The 254 shares the Reporting Person purchased on December 2, 2021 are held by Jack Levine and Susan Levine JTWROS, a joint tenant account of the Reporting Person and his wife. |
(3) | The 1,523 shares the Reporting Person purchased on December 2, 2021 are held by Jack Levine and Susan Levine JTWROS, a joint tenant account of the Reporting Person and his wife. |
(4) | The 18,000 shares the Reporting Person purchased on December 3, 2021 are held by Jack Levine and Susan Levine JTWROS, a joint tenant account of the Reporting Person and his wife. |
(5) | Jack Levine is the Manager of Cameo Life Sciences Investments LLC and beneficially owns 186,010 shares of common stock, which are held by Cameo Life Sciences Investments, LLC. |