Form 3 ACTELIS NETWORKS INC For: May 12 Filed by: Domanovitz Elad
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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
1. Name and Address of Reporting Person
2. Date of Event Requiring Statement
3. Issuer Name
Ticker or Trading Symbol
ACTELIS NETWORKS INC [ ASNS ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
5. If Amendment, Date of Original Filed
6. Individual or Joint/Group Filing (Check
|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)|
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|
|/s/ Elad Domanovitz||05/17/2022|
|** 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.|
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