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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1. Name and Address of Reporting Person*
DAUWALTER JAMES E

(Last) (First) (Middle)
BIODRAIN MEDICAL INC.
2060 CENTRE POINTE BLVD., SUITE 7

(Street)
MENDOTA HEIGHTS MN 55120

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
10/19/2009
3. Issuer Name and Ticker or Trading Symbol
BioDrain Medical, Inc. [ BIOR ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director 10% Owner
Officer (give title below) Other (specify below)
5. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Beneficially Owned
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 771,429 D
Common Stock 50,000 I By Familial Relationship(1)
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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
Option to purchase common stock 08/11/2008 08/11/2013 Common Stock 10,000 0.35 I By Familial Relationship(2)
Option to purchase common stock 04/15/2009 08/11/2013 Common Stock 10,000 0.35 I By Familial Relationship(2)
Option to purchase common stock 05/30/2009 08/11/2013 Common Stock 10,000 0.35 I By Familial Relationship(2)
Option to purchase common stock (3) 08/11/2013 Common Stock 20,000 0.35 I By Familial Relationship(2)
Warrant to purchase common stock 08/02/2008 07/02/2011 Common Stock 571,429 0.46 D
Warrant to purchase common stock 04/30/2009 04/29/2012 Common Stock 200,000 0.65 D
Explanation of Responses:
1. These shares are held by David Dauwalter, the adult son of James Dauwalter and an employee of BioDrain Medical, Inc. James Dauwalter disavows any beneficial interest in the shares.
2. The option shares are held by David Dauwalter, the adult son of James Dauwalter and an employee of BioDrain Medical, Inc. James Dauwalter disavows any beneficial interest in the shares.
3. Exercisable only upon achieving certain performance conditions and are, therefore, not exercisable within 60 days.
/s/ James Dauwalter 12/02/2009
** 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).
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