SEC FORM
4
SEC Form 4
| FORM 4 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
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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| OMB APPROVAL |
| OMB Number: |
3235-0287 |
| Estimated average burden |
| hours per response: |
0.5 |
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b). |
1. Name and Address of Reporting Person*
| C/O MIMEDX GROUP, INC. |
| 1775 WEST OAK COMMONS COURT, NE |
(Street)
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2. Issuer Name and Ticker or Trading Symbol
MIMEDX GROUP, INC.
[ MDXG ]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
| X |
Director |
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10% Owner |
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Officer (give title below) |
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Other (specify below) |
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|
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3. Date of Earliest Transaction
(Month/Day/Year)
01/22/2020
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4. If Amendment, Date of Original Filed
(Month/Day/Year)
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6. Individual or Joint/Group Filing (Check Applicable Line)
| X |
Form filed by One Reporting Person |
|
Form filed by More than One Reporting Person |
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| Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned |
|---|
| 1. Title of Security (Instr.
3)
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2. Transaction Date
(Month/Day/Year) |
2A. Deemed Execution Date, if any
(Month/Day/Year) |
3. Transaction Code (Instr.
8)
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4. Securities Acquired (A) or Disposed Of (D) (Instr.
3, 4 and 5)
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5.
Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr.
3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr.
4)
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7. Nature of Indirect Beneficial Ownership (Instr.
4)
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| Code |
V |
Amount |
(A) or (D) |
Price |
| Common Stock |
01/22/2020 |
|
M
|
|
15,000 |
A |
$1.2
|
15,000 |
D |
|
| Common Stock |
01/22/2020 |
|
J
|
V |
15,000 |
D |
$0
|
0 |
D |
|
| Common Stock |
01/22/2020 |
|
J
|
V |
15,000 |
A |
$0
|
1,475,628 |
I |
by Family Trust |
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
|
|---|
| 1. Title of Derivative Security (Instr.
3)
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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)
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6. Date Exercisable and Expiration Date
(Month/Day/Year) |
7. Title and Amount of Securities Underlying Derivative Security (Instr.
3 and 4)
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8. Price of Derivative Security (Instr.
5)
|
9.
Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr.
4)
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10. Ownership Form: Direct (D) or Indirect (I) (Instr.
4)
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11. Nature of Indirect Beneficial Ownership (Instr.
4)
|
| Code |
V |
(A) |
(D) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
| Stock Option |
$1.2
|
01/22/2020 |
|
M |
|
|
15,000 |
05/11/2011 |
05/10/2020 |
Common Stock |
15,000 |
$1.2
|
0 |
D |
|
| Stock Option |
$1.1
|
|
|
|
|
|
|
12/14/2012 |
12/13/2021 |
Common Stock |
15,000 |
|
15,000 |
D |
|
| Stock Option |
$2.94
|
|
|
|
|
|
|
10/31/2013 |
10/30/2022 |
Common Stock |
15,000 |
|
15,000 |
D |
|
| Stock Option |
$6.6
|
|
|
|
|
|
|
05/09/2014 |
05/08/2023 |
Common Stock |
15,000 |
|
15,000 |
D |
|
| Stock Option |
$6.28
|
|
|
|
|
|
|
07/28/2015 |
07/27/2024 |
Common Stock |
15,000 |
|
15,000 |
D |
|
| Explanation of Responses: |
|
|
| Remarks: |
|
|
/s/ David Wisniewski, as power of attorney for Charles E. Koob |
01/23/2020 |
|
** Signature of Reporting Person |
Date |
| Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. |
| * 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). |
| Note: File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure. |
| 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 Number. |
POWER OF ATTORNEY
Know all by these presents, that the undersigned hereby constitutes and appoints the Secretary and any Assistant Secretary, or any of them signing individually, and with full power of substitution, the undersigned's true and lawful attorney-in-fact to: (i) prepare, execute in the undersigned's name and on the undersigned's behalf, and submit to the U.S. Securities and Exchange Commission (the "SEC") a Form ID, including amendments thereto, and any other documents necessary or appropriate to obtain codes and passwords enabling the undersigned to make electronic filings with the SEC of reports required by Section 16(a) of the Securities Exchange Act of 1934 or any rule or regulation of the SEC; and (ii) to execute and file on the undersigned's behalf all Forms 3, 4, and 5 (including any amendments thereto) that the undersigned may be required to file with the SEC as a result of the undersigned's ownership of or transactions in securities of MiMedx Group, Inc.
This Power of Attorney shall remain in full force and effect until the undersigned is no longer required to file Forms 3, 4, and 5 with regard to the undersigned's ownership of or transactions in securities of MiMedx Group, Inc., unless earlier revoked in writing. The undersigned acknowledges that the attorneys-in-fact are not assuming any of the undersigned's responsibilities to comply with Section 16 of the Securities Exchange Act of 1934.
Dated: October 21, 2019 /s/ Charles E. Koob
Sworn to and subscribed before me this 21st day of October, 2019.
(SEAL)
Claudia Hinckley Bell, Notary Public
Cobb County, GA
My Commission Expires January 30, 2021
/s/ Claudia Hinckley Bell
Notary Public
