Tom Kubota - Sep 22, 2023 Form 4 Insider Report for PACIFIC HEALTH CARE ORGANIZATION INC (PFHO)

Role
CEO & President, Director, 10%+ Owner
Signature
/s/ Tom Kubota
Stock symbol
PFHO
Transactions as of
Sep 22, 2023
Transactions value $
$328
Form type
4
Date filed
9/25/2023, 06:30 PM
Previous filing
Sep 13, 2023
Next filing
Sep 28, 2023
SEC
View on sec.gov

Transactions Table

Type Sym Class Transaction Value $ Shares Change % * Price $ Shares After Date Ownership Footnotes
transaction PFHO Common Purchase $328 +400 +0% $0.82 8.27M Sep 22, 2023 Direct F1

Derivative Securities (e.g., puts, calls, warrants, options, convertible securities)

Type Sym Class Transaction Value $ Shares Change % * Price $ Shares After Date Underlying Class Amount Exercise Price Ownership Footnotes
holding PFHO Series A Preferred 16K Sep 22, 2023 Common Stock 16K $0.00 Direct F1, F2
* An asterisk sign (*) next to the price indicates that the price is likely invalid.

Explanation of Responses:

Id Content
F1 The Reporting Person holds the shares through the Tom Kubota Revocable Trust of 2013 (the "Trust"). The Reporting Person is the sole Trustee of the Trust. As such, the Reporting Person may be deemed to have voting and/or investment power over the shares held by the Trust and therefore may be deemed to be the beneficial owner of those shares.
F2 The Series A Preferred Stock converts into Common Stock of the Issuer on a 1:1 basis at any time at the election of the Reporting Person and has no expiration date.