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
|
| 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 AQUABOUNTY TECHNOLOGIES, INC. |
| 2 MILL & MAIN PLACE, SUITE 395 |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
04/30/2019
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3. Issuer Name and Ticker or Trading Symbol
AquaBounty Technologies, Inc.
[ AQB ]
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4. 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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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 |
|
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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| Common Stock |
172 |
D |
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Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
|
|---|
| 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 |
| Explanation of Responses: |
| Remarks: |
|
|
/s/ David A. Frank, Name: David A. Frank, attorney-in-fact |
05/01/2019 |
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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. |
AQUABOUNTY TECHNOLOGIES, INC.
POWER OF ATTORNEY - SEC Forms 3, 4 and 5 Filings
The undersigned hereby constitutes and appoints David A. Frank, Chief
Financial Officer and Treasurer, and Christopher H. Martin, General Counsel, of
AquaBounty Technologies, Inc. (the "Company"), with full power of substitution,
as the undersigned's true and lawful authorized representatives and attorneys-
in-fact to:
(1) execute for and on behalf of the undersigned, in the undersigned's
capacity as an officer or director of the Company, Forms 3, 4, and 5,
and any and all amendments thereto, in accordance with Section 16 of
the Securities and Exchange Act of 1934, as amended (the "1934 Act"),
and the rules and regulations promulgated thereunder;
(2) do and perform any and all acts for and on behalf of the undersigned
that may be necessary or desirable to complete the execution of any
such form or schedule and the timely filing of such form or schedule
with the United States Securities and Exchange Commission and any
stock exchange or stock market or other authority; and
(3) take any other action of any type whatsoever in connection with the
foregoing that, in the opinion of each such attorney-in-fact, may be
of benefit to, in the best interest of, or legally required by, the
undersigned, it being understood that the documents executed by such
attorney-in-fact on behalf of the undersigned pursuant to this Power
of Attorney will be in such form and will contain such terms and
conditions as such attorney-in-fact may approve in such attorney-in-
fact's discretion.
The undersigned hereby grants to such attorneys-in-fact full power and
authority to do and perform all and every act and thing whatsoever requisite,
necessary, or proper to be done in the exercise of any of the rights and powers
herein granted, as fully to all intents and purposes as the undersigned might
or could do if personally present, with full power of substitution or
revocation, hereby ratifying and confirming all that each such attorney-in-
fact, or such attorney-in-fact's substitute, will 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 each foregoing attorney-in-fact, in
service in such capacity at the request of the undersigned, is not assuming,
nor is the Company assuming, any of the undersigned's responsibilities to
comply with Section 16 or any other provision of the 1934 Act. Notwithstanding
the filing of these reports on your behalf by the Company, the undersigned will
remain responsible for the accuracy of all information provided to the Company
in connection with the filing of such reports.
This Power of Attorney will remain in full force and effect until the
undersigned is no longer required to file Forms 3, 4, and 5 with respect to
the undersigned's holding of, or transactions in, securities issued by Company,
unless earlier revoked by the undersigned in a signed writing delivered to the
foregoing attorneys-in-fact.
Signed: /s/ Jeffrey T. Perez
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Print Name: Jeffrey T. Perez
Dated: May 1, 2019
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[Signature page to Power of Attorney - SEC Forms 3, 4 and 5 Filings]
