Tom Kubota - 20 Aug 2021 Form 4 Insider Report for PACIFIC HEALTH CARE ORGANIZATION INC (PFHO)

Role: CEO & President, Director, 10%+ Owner
Signature: /s/ Tom Kubota
Issuer symbol: PFHO
Transactions as of: 20 Aug 2021
Net transactions value: +$11,110
Form type: 4
Filing time: 23 Aug 2021, 18:33:23 UTC
Next filing: 14 Sep 2021
SEC: View on sec.gov

Transactions Table

Type	Sym	Class	Transaction	Value $	Shares	Change %	* Price $	Shares After	Date	Ownership	Footnotes
transaction	PFHO	Common	Purchase	$11,110	+11,000	+0.14%	$1.01	7,908,000	20 Aug 2021	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						16,000	20 Aug 2021	Common Stock	16,000	$0.000000	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.