SEC FORM
3
SEC Form 3
| 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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| OMB APPROVAL |
| OMB Number: |
3235-0104 |
| Estimated average burden |
| hours per response: |
0.5 |
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1. Name and Address of Reporting Person*
| C/O HELIUS MEDICAL TECHNOLOGIES, INC. |
| 642 NEWTOWN YARDLEY ROAD, SUITE 100 |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
06/10/2020
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3. Issuer Name and Ticker or Trading Symbol
HELIUS MEDICAL TECHNOLOGIES, INC.
[ HSDT ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
| X |
Director |
|
10% Owner |
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Officer (give title below) |
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Other (specify below) |
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5. 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 |
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Form filed by More than One Reporting Person |
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| Table I - Non-Derivative Securities Beneficially Owned |
|---|
| 1. Title of Security (Instr.
4)
|
2.
Amount of Securities Beneficially Owned (Instr.
4)
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3. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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4. Nature of Indirect Beneficial Ownership (Instr.
5)
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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)
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2. Date Exercisable and Expiration Date
(Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr.
4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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6. Nature of Indirect Beneficial Ownership (Instr.
5)
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| Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
| Stock Option (Right to Buy) |
|
06/09/2030 |
Class A Common Stock |
36,697 |
0.545 |
D |
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| Explanation of Responses: |
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| Remarks: |
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/s/ Philippe Deschamps, Attorney-in-Fact |
06/12/2020 |
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** 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. |
LIMITED POWER OF ATTORNEY FOR
SECTION 16 REPORTING OBLIGATIONS
Know all by these present that the undersigned hereby constitutes and appoints
each of Eileen Overbaugh, Irina Ishak and Philippe Deschamps as their true and
lawful attorney-in-fact to:
(1) execute for and on behalf of the undersigned Schedules 13D and 13G, Form ID
and Forms 3, 4 and 5 in accordance with Sections 13 and 16(a) of the Securities
Exchange Act of 1934 (the "Exchange Act") and the rules thereunder;
(2) do and perform any and all acts for and on behalf of the undersigned which
may be necessary or desirable to complete the execution of any such Schedules
13D or 13G, Form ID application for EDGAR codes, and Forms 3, 4 or 5, and the
timely filing of such Forms with the United States Securities and Exchange
Commission and any other authority; and
(3) take any other action of any type whatsoever in connection with the
foregoing which, in the opinion of such attorney-in-fact, may be of benefit to,
in the best interest of, or legally required by, the undersigned, including,
without limitation, the execution and filing of a Form 4 with respect to a
transaction which may be reported on a Form 5, it being understood that the
documents executed by such attorney-in-fact on behalf of the undersigned
pursuant to this Power of Attorney shall be in such form and shall contain such
terms and conditions as such attorney-in-fact may approve in their discretion.
The undersigned hereby grants to each such attorney-in-fact full power and
authority to do and perform all and every act and thing whatsoever requisite,
necessary and proper to be done in the exercise of any of the rights and powers
herein granted, as fully and to all intents and purposes as he might or could do
in person, with full power of substitution and resubstitution, hereby ratifying
and confirming all that such attorney-in-fact, or their substitute or
substitutes, shall lawfully do or cause to be done by virtue of this Power of
Attorney and the rights and powers herein granted. The undersigned acknowledges
that the foregoing attorneys-in-fact, in serving in such capacity at the request
of the undersigned, are not assuming any of the undersigned's responsibilities
to comply with Sections 13 and 16 of the Exchange Act.
This Power of Attorney shall remain in full force and effect until the
undersigned is no longer required to file any Schedules 13D and 13G and Forms 3,
4 and 5 in accordance with Sections 13 and 16(a) of the Exchange Act and the
rules thereunder with respect to the undersigned's holdings of and transactions
in securities issued by Helius Medical Technologies, Inc., unless earlier
revoked by the undersigned in a signed writing delivered to the foregoing
attorneys-in-fact.
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be
executed as May 28, 2020.
_/S/ Jeffrey Mathiesen___________
Signature
_Jeffrey Mathiesen_______________
Print Name
STATE OF New York
COUNTY OF Westchester
On this 28th day of May, 2020, Jeffrey Mathiesen personally appeared before me,
and acknowledged that s/he executed the foregoing instrument for the purposes
therein contained.
IN WITNESS WHEREOF, I have hereunto set my hand and official seal.
_Bettina Christine Elstroth_______
Notary Public
_October 5, 2022___________________
My Commission Expires:
