Form 3 SURGALIGN HOLDINGS, INC. For: Aug 02 Filed by: Amoruso Paolo
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August 11, 2022 9:44 AM EDT
| 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
*
| 520 LAKE COOK ROAD |
| SUITE 315 |
(Street)
|
2. Date of Event Requiring Statement
(Month/Day/Year)
08/02/2022
|
3. Issuer Name
and
Ticker or Trading Symbol
SURGALIGN HOLDINGS, INC.
[
SRGA
]
|
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
|
Director |
|
10% Owner |
| X |
Officer (give title below) |
|
Other (specify below) |
| Chief Legal Officer |
|
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
|
4,000
|
D
|
|
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: |
|
By Jessica Rumschlag as Attorney in Fact |
08/10/2022 |
|
** 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. |
LIMITED POWER OF ATTORNEY FOR SECTION 16 REPORTING OBLIGATIONS
The undersigned makes, constitutes and appoints each of David Lyle, Terry Rich,
and Jessica Rumschlag as the undersigneds true and lawful attorney-in-fact, with
full power and authority as described below on behalf of and in the name, place
and stead of the undersigned to: (1) prepare, execute, acknowledge, deliver and
file Forms 3, 4 and 5 (including any amendments to such Forms) with respect to
the securities of Surgalign Holdings, Inc., a Delaware corporation (the
Company), with the United States Securities and Exchange Commission, any
national securities exchanges and the Company, as considered necessary or
advisable under Section 16(a) of the Securities Exchange Act of 1934 and the
rules and regulations promulgated thereunder, as amended from time to time (the
Exchange Act); (2) seek or obtain, as the undersigneds representative and on the
undersigneds behalf, information on transactions in the Companys securities from
any third party, including brokers, employee benefit plan administrators and
trustees, and the undersigned authorizes any such person to release any such
information to the undersigned and approves and ratifies any such release of
information; and (3) perform any and all other acts which in the discretion of
such attorney-in-fact are necessary or desirable for and on behalf of the
undersigned in connection with the above. The undersigned acknowledges that: (1)
this Limited Power of Attorney authorizes, but does not require, such
attorney-in-fact to act in his or her discretion on information provided to such
attorney-in-fact without independent verification of such information; (2) any
documents prepared and/or executed by such attorney-in-fact on behalf of the
undersigned pursuant to this Limited Power of Attorney will be in such form and
will contain such information and disclosure as such attorney-in-fact, in his or
her discretion, deems necessary or desirable; (3) neither the Company nor such
attorney-in-fact assumes: (i) any liability for the undersigneds responsibility
to comply with the requirement of the Exchange Act; (ii) any liability of the
undersigned for any failure to comply with such requirements; or (iii) any
obligation or liability of the undersigned for profit disgorgement under Section
16(b) of the Exchange Act; and (4) this Limited Power of Attorney does not
relieve the undersigned from responsibility for compliance with the undersigneds
obligations under the Exchange Act, including without limitation the reporting
requirements under Section 16 of the Exchange Act. The undersigned gives and
grants the above attorneys-in-fact full power and authority to do and perform
all and every act and thing whatsoever requisite, necessary or appropriate to be
done in and about the above matters as fully to all intents and purposes as the
undersigned might or could do if present, ratifying all that such
attorney-in-fact of, for and on behalf of the undersigned, shall lawfully do or
cause to be done by virtue of this Limited Power of Attorney. This Limited Power
of Attorney shall remain in full force and effect until revoked by the
undersigned in a signed writing delivered to such attorney-in-fact or until the
undersigned is no longer required to file Forms 3, 4, and 5 with regards to the
undersigneds ownership of or transaction in the Companys securities.
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be
executed as of this 8th day of August, 2022.
/s/ Paolo Amoruso
Signature
Paolo Amoruso
Print Name
State of Texas
County of Harris
This instrument was acknowledged before me on this 8th day of August, 2022 by
Paolo G. Amoruso.
/s/ Erica Tucker
Signature of Notary
My commission expires: 11/15/2025
My commission #: 133447518
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