Tom Kubota - May 21, 2024 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
May 21, 2024
Transactions value $
$71
Form type
4
Date filed
5/23/2024, 08:52 PM
Previous filing
May 20, 2024
Next filing
May 29, 2024

Transactions Table

Type Sym Class Transaction Value $ Shares Change % * Price $ Shares After Date Ownership Footnotes
transaction PFHO Common Purchase $71.00 +100 +0% $0.71 8.35M May 21, 2024 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 May 21, 2024 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.