SEC FORM
4
SEC Form 4
FORM 4 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
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: |
3235-0287 |
Estimated average burden |
hours per response: |
0.5 |
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b). |
1. Name and Address of Reporting Person*
(Street)
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2. Issuer Name and Ticker or Trading Symbol
Skyline Medical Inc.
[ SKLN ]
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5. 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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3. Date of Earliest Transaction
(Month/Day/Year) 08/19/2013
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4. 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 Acquired, Disposed of, or Beneficially Owned |
1. Title of Security (Instr.
3)
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2. Transaction Date
(Month/Day/Year) |
2A. Deemed Execution Date, if any
(Month/Day/Year) |
3. Transaction Code (Instr.
8)
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4. Securities Acquired (A) or Disposed Of (D) (Instr.
3, 4 and 5)
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5.
Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr.
3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr.
4)
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7. Nature of Indirect Beneficial Ownership (Instr.
4)
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Code |
V |
Amount |
(A) or (D) |
Price |
Common Stock, $.01 par value |
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20,000 |
I |
By the Reporting Person as custodian for Ilan B. Dreyfuss UTMA/UGMA
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Common Stock, $.01 par value |
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20,000 |
I |
By the Reporting Person as Custodian for Gil N. Dreyfuss Unif Tran to Minors Act
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Common Stock, $.01 par value |
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10,000 |
I |
By Trust FBO Ilan B. Dreyfuss
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Common Stock, $.01 par value |
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10,000 |
I |
By Trust FBO Gil N. Dreyfuss
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Common Stock, $.01 par value |
08/19/2013 |
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X |
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714,286 |
A |
$0.15
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1,578,551
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D |
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Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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1. Title of Derivative Security (Instr.
3)
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2. Conversion or Exercise Price of Derivative Security
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3. Transaction Date
(Month/Day/Year) |
3A. Deemed Execution Date, if any
(Month/Day/Year) |
4. Transaction Code (Instr.
8)
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5.
Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr.
3, 4 and 5)
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6. Date Exercisable and Expiration Date
(Month/Day/Year) |
7. Title and Amount of Securities Underlying Derivative Security (Instr.
3 and 4)
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8. Price of Derivative Security (Instr.
5)
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9.
Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr.
4)
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10. Ownership Form: Direct (D) or Indirect (I) (Instr.
4)
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11. Nature of Indirect Beneficial Ownership (Instr.
4)
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Code |
V |
(A) |
(D) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
Warrant to purchase Common Stock |
$0.15
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08/19/2013 |
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X |
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714,286 |
11/02/2012 |
11/02/2017 |
Common Stock, $.01 par value |
714,286 |
$0
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0 |
D |
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Explanation of Responses: |
Remarks: |
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/Bob Myers/ As Attorney-in-fact for Arnon Dreyfuss |
08/29/2013 |
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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
4
(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. |
POWER OF ATTORNEY
For Executing Forms 3, 4 and 5
Know all by these presents, that the undersigned hereby
constitutes and appoints Bob Myers his true and lawful
attorneys-in-fact to:
1. Execute for and on behalf of the undersigned Initial
Statements of Beneficial Ownership of Securities on Form 3,
Statements of Changes of Beneficial Ownership of Securities on
Form 4 and Annual Statements of Beneficial Ownership of
Securities on Form 5, for the purpose of reporting transactions
by the undersigned in securities issued by Skyline Medical Inc.
in accordance with Section 16(a) of the Securities Exchange
Act of 1934 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 of any such Form 3,4 or 5 and the timely
filing thereof with the United States Securities and Exchange
Commission and any other applicable governmental or regulatory
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, 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 his
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 to all intents and purposes as such attorney-
in-fact might or could do if personally present, with full
power of substitution or revocation, hereby ratifying and
confirming all that such attorney-in-fact, or his 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 Section 16 of
the Securities Exchange Act of 1934.
This Power of Attorney shall 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 holdings of and
transactions in securities issued by Skyline Medical Inc.,
unless earlier revoked by the undersigned in a signed writing
delivered to the foregoing attorneys-in-fact.
IN WITNESS WHEREOF, the undersigned has executed this Power of
Attorney as of this 11th day of August, 2013.
/s/ Arnon I. Dreyfuss
Arnon I. Dreyfuss
986156