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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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*
Kornberg Joshua

(Last) (First) (Middle)
2915 COMMERS DRIVE, SUITE 900

(Street)
EAGAN MN 55121

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
Skyline Medical Inc. [ SKLN ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director X 10% Owner
X Officer (give title below) Other (specify below)
CEO and President
3. Date of Earliest Transaction (Month/Day/Year)
08/31/2015
4. 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 Acquired, Disposed of, or Beneficially Owned
1. Title of Security (Instr. 3) 2. Transaction Date (Month/Day/Year) 2A. Deemed Execution Date, if any (Month/Day/Year) 3. Transaction Code (Instr. 8) 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 7. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V Amount (A) or (D) Price
Common Stock, $.01 par value 08/31/2015 J(1) 2,778 A (1) 6,961 D
Common Stock, $.01 par value 805,982 I By SOK Partners(2)
Common Stock, $.01 par value 615,281 I by Atlantic Partners Alliance LLC(3)
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 3) 2. Conversion or Exercise Price of Derivative Security 3. Transaction Date (Month/Day/Year) 3A. Deemed Execution Date, if any (Month/Day/Year) 4. Transaction Code (Instr. 8) 5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) 6. Date Exercisable and Expiration Date (Month/Day/Year) 7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4) 8. Price of Derivative Security (Instr. 5) 9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) 10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 11. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V (A) (D) Date Exercisable Expiration Date Title Amount or Number of Shares
Series A Convertible Preferred Stock, $.01 par value (4) 08/31/2015 J(1) 250 (4) (5) Common Stock (4) (1) 0 D
Series B Convertible Preferred Stock (6) 08/31/2015 J(1) 2,778 02/28/2016 (5) Common Stock 2,778 (1) 2,778 D
Series A Warrants $4.95 08/31/2015 J(1) 11,112 (7) 08/31/2020 Common Stock 11,112 (1) 11,112 D
Senior Convertible Note $11.25(8) 08/31/2015 J(8) $100,000 07/23/2014 07/23/2015(9) Common Stock (8) $0(8) 0 I By SOK Partners LLC(2)
Explanation of Responses:
1. Pursuant to an Exchange Agreement with the majority holders of Series A Convertible Preferred Stock (the "Series A Shares"), one of which is the Reporting Person, the holders agreed to exchange their Series A Shares for Units under the same terms as the Issuer's public offering which closed on 8-31-2015. Each Unit consists of 1 share of Common Stock, 1 share of Series B Convertible Preferred Stock and 4 Series A Warrants. The reporting person exchanged 250 Series A Shares for 2,778 Units.
2. A limited liability company of which the Reporting Person is one of the managers. The Reporting Person disclaims beneficial ownership of such shares, except for those as which he may have a pecuniary interest therein.
3. A limited liability company, of which the Reporting Person is a member. The Reporting Person disclaims beneficial ownership of such shares, except for those as which he may have a pecuniary interest therein.
4. The Series A Preferred Stock was convertible into shares of common stock.
5. No expiration date.
6. The Series B Convertible Preferred stock is convertible into Common Stock on a one-for-one basis.
7. The warrants are exercisable upon the separation of the Units provided that all Series A Warrants in a given Unit may be exercised for cash at any time commencing 30 days after the issuance date.
8. On July 23, 2014, the Issuer issued a senior convertible note in the original amount of $122,195.60 (the "Note") to SOK Partners, LLC ("SOK Partners"). The Note was convertible at any time after issuance, at the holder's option, into shares of the company's common stock, par value $0.01 per share (the "Common Stock"), at a conversion price equal to the lesser of (i) 72.5% (or if an event of default has occurred and is continuing, 70%) of the average of the lowest three volume weighted average prices of the Common Stock during the ten consecutive trading days prior to the conversion date, and (ii) $11.25 (as adjusted for stock splits, stock dividends, recapitalizations or similar events). On August 31, 2015, in consideration of the payment by the Issuer of $167,694.12, the outstanding principal, accrued interest and penalities payable under the Note were repaid and the Note was canceled.
9. The Note was due on September 1, 2015, as extended by agreement of the holder.
/s/ Joshua Kornberg 09/17/2015
** 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).
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