FORM 3 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 INITIAL STATEMENT OF 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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1. Name and Address of Reporting Person*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 02/14/2012 |
3. Issuer Name and Ticker or Trading Symbol
Sunshine Heart, Inc. [ SSH ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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5. If Amendment, Date of Original Filed
(Month/Day/Year) 02/28/2012 |
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6. Individual or Joint/Group Filing (Check Applicable Line)
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Table I - Non-Derivative Securities Beneficially Owned | |||
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1. Title of Security (Instr. 4) | 2. Amount of Securities Beneficially Owned (Instr. 4) | 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 4. Nature of Indirect Beneficial Ownership (Instr. 5) |
Common Stock | 750,356 | I | By CM Capital Venture 4A A/C(1) |
Common Stock | 750,356 | I | By CM Capital Venture 4B A/C(2) |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
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1. Title of Derivative Security (Instr. 4) | 2. Date Exercisable and Expiration Date (Month/Day/Year) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 6. Nature of Indirect Beneficial Ownership (Instr. 5) | ||
Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Common Stock Warrant (right to buy) | (3) | 12/08/2014 | Common Stock | 188,393(4) | 6.5114 | I | By CM Capital Venture 4A A/C(1) |
Common Stock Warrant (right to buy) | (3) | 12/08/2014 | Common Stock | 188,393(4) | 6.5114 | I | By CM Capital Venture 4B A/C(2) |
1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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Explanation of Responses: |
1. Represents securities held directly by CM Capital Venture 4A A/C. CM Capital Venture 4A A/C is a fund affiliated with CM Capital Investments Pty Ltd. Mr. Mark Harvey, a director of the Issuer, shares voting and investment power with other partners and may be deemed to be a beneficial owner of the reported securities. Mr. Harvey disclaims indirect beneficial ownership of the reported securities except to the extent of his pecuniary interest. This report shall not be deemed an admission that Mr. Harvey is the beneficial owner of such securities for purposes of Section 16 or for any other purpose. |
2. Represents securities held directly by CM Capital Venture 4B A/C. CM Capital Venture 4B A/C is a fund affiliated with CM Capital Investments Pty Ltd. Mr. Mark Harvey, a director of the Issuer, shares voting and investment power with other partners and may be deemed to be a beneficial owner of the reported securities. Mr. Harvey disclaims indirect beneficial ownership of the reported securities except to the extent of his pecuniary interest. This report shall not be deemed an admission that Mr. Harvey is the beneficial owner of such securities for purposes of Section 16 or for any other purpose. |
3. Immediately exercisable. |
4. This Form 3 amends the number of derivative securities beneficially owned in the granted warrant. |
/s/ Jeffrey Mathiesen, Chief Financial Officer of Issuer | 05/10/2012 | |
/s/ Jeffrey Mathiesen, Chief Financial Officer of Issuer | 05/10/2012 | |
/s/ Jeffrey Mathiesen, Chief Financial Officer of Issuer | 05/10/2012 | |
** 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 5 (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. |