| 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
|
| OMB APPROVAL |
| OMB Number: |
3235-0104 |
| Expires: |
December 31, 2014 |
| Estimated average burden |
| hours per response: |
0.5 |
|
|
1. Name and Address of Reporting Person
*
| C/O LAIRD SUPERFOOD, INC. |
| 275 W LUNDGREN MILL DR |
(Street)
|
2. Date of Event Requiring Statement
(Month/Day/Year)
09/24/2021
|
3. Issuer Name
and
Ticker or Trading Symbol
Laird Superfood, Inc.
[
LSF
]
|
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)
|
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 |
| Explanation of Responses: |
| Remarks: |
| No securities are beneficially owned. |
|
/s/Valerie Ells as attorney-in-fact for Patrick Reginald Gaston |
09/28/2021 |
|
** 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
Know all by these presents, that the undersigned hereby makes,
constitutes and appoints each of Kim Ausk and Valerie Ells, or any of them
acting singly, and with full power of substitution and re-substitution, the
undersigned's true and lawful attorney-in-fact (each of such persons and
their substitutes being referred to herein as the "Attorney-in-Fact"), with
full power to act for the undersigned and in the undersigned's name, place
and stead, in any and all capacities, to:
1. Prepare, execute, and submit to the Securities and Exchange Commission
("SEC") a Form ID, including amendments thereto, and any other documents
necessary or appropriate to obtain codes and passwords enabling the
undersigned to make electronic filings with the SEC of reports required or
considered by the Attorney-in-Fact to be advisable under Section 16 of the
Securities Exchange Act of 1934 (the "Exchange Act") or any rule or
regulation of the SEC;
2. Prepare, execute and submit to the SEC, Laird Superfood, Inc. (the
"Company"), and/or any national securities exchange on which the Company's
securities are listed any and all reports (including any amendments
thereto) the undersigned is required to file with the SEC, or which the
Attorney-in-Fact considers it advisable to file with the SEC, under Section
16 of the Exchange Act or any rule or regulation thereunder, or under Rule
144 under the Securities Act of 1933 ("Rule 144"), with respect to the any
security of the Company, including Forms 3, 4 and 5 and Forms 144; and
3. Obtain, as the undersigned's representative and on the undersigned's
behalf, information regarding transactions in the Company's securities from
any third party, including the Company and any brokers, dealers, employee
benefit plan administrators and trustees, and the undersigned hereby
authorizes any such third party to release any such information to the
Attorney-in-Fact.
The undersigned acknowledges that:
a) This Power of Attorney authorizes, but does not require, the
Attorney-in-Fact to act in his or her discretion on information provided to
such Attorney-in-Fact without independent verification of such information;
b) Any documents prepared or executed by the Attorney-in-Fact on behalf of
the undersigned pursuant to this Power of Attorney will be in such form and
will contain such information as the Attorney-in-Fact, in his or her
discretion, deems necessary or desirable;
c) Neither the Company nor the Attorney-in-Fact assumes any liability for
the undersigned's responsibility to comply with the requirements of Section
16 of the Exchange Act or Rule 144, any liability of the undersigned for
any failure to comply with such requirements, or any liability of the
undersigned for disgorgement of profits under Section 16(b) of the Exchange
Act; and
d) This Power of Attorney does not relieve the undersigned from
responsibility for compliance with the undersigned's obligations under
Section 16 of the Exchange Act, including, without limitation, the
reporting requirements under Section 16 of the Exchange Act.
The undersigned hereby grants to the Attorney-in-Fact full power and
authority to do and perform each and every act and thing requisite,
necessary or advisable to be done in connection with the foregoing, as
fully, to all intents and purposes, as the undersigned might or could do in
person, hereby ratifying and confirming all that the Attorney-in-Fact, or
his or her substitute or substitutes, shall lawfully do or cause to be done
by authority of this Power of Attorney.
This Power of Attorney shall remain in full force and effect until the
undersigned is no longer required to file Forms 4 or 5 or Forms 144 with
respect to the undersigned's holdings of and transactions in securities of
the Company, unless earlier revoked by the undersigned in a signed writing
delivered to the Attorney-in-Fact. This Power of Attorney revokes all
previous powers of attorney with respect to the subject matter of this
Power of Attorney.
IN WITNESS WHEREOF, the undersigned has executed this Power of Attorney as
of 9/22/2021.
Signature /s/ Patrick Gaston
Print Name: Patrick Gaston
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