Form 4 SURGALIGN HOLDINGS, INC. For: Feb 01 Filed by: STOLPER MARK
February 2, 2021 10:44 AM EST
| 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
|
| OMB APPROVAL |
| OMB Number: |
3235-0287 |
| Expires: |
December 31, 2014 |
| Estimated average burden |
| hours per response: |
0.5 |
|
|
|
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
*
| 520 LAKE COOK ROAD |
| SUITE 315 |
(Street)
|
2. Issuer Name
and
Ticker or Trading Symbol
SURGALIGN HOLDINGS, INC.
[
SRGA
]
|
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
| X |
Director |
|
10% Owner |
|
Officer (give title below) |
|
Other (specify below) |
|
|
3. Date of Earliest Transaction
(Month/Day/Year)
02/01/2021
|
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
|
02/01/2021 |
|
P |
|
16,667
|
A
|
$
1.5
|
108,143
|
D
|
|
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 |
| Explanation of Responses: |
|
By Joshua H. DeRienzis as attorney in fact |
02/02/2021 |
|
** 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. |
LIMITED POWER OF ATTORNEY FOR SECTION 16 REPORTING OBLIGATIONS
The undersigned makes, constitutes and appoints each of Jonathon M. Singer,
Joshua H. DeRienzis 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 4th day of January, 2021.
/s/ Mark D. Stolper
Signature
Mark D. Stolper
Print Name
State of California
County of Los Angeles
This instrument was acknowledged before me on this 4th day of January, 2021 by
Mark Stolper.
/s/ Ydairi R. Ramos
Signature of Notary
My commission expires: June 10, 2023
My commission #: 2292450
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