SEC FORM
3
SEC Form 3
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
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OMB APPROVAL |
OMB Number: |
3235-0104 |
Estimated average burden |
hours per response: |
0.5 |
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1. Name and Address of Reporting Person*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 08/15/2022
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3. Issuer Name and Ticker or Trading Symbol
ReShape Lifesciences Inc.
[ RSLS ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X |
Director |
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10% Owner |
X |
Officer (give title below) |
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Other (specify below) |
President and CEO |
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5. If Amendment, Date of Original Filed
(Month/Day/Year)
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6. Individual or Joint/Group Filing (Check Applicable Line)
X |
Form filed by One Reporting Person |
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Form filed by More than One Reporting Person |
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Table I - Non-Derivative Securities Beneficially Owned |
1. Title of Security (Instr.
4)
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2.
Amount of Securities Beneficially Owned (Instr.
4)
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3. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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4. Nature of Indirect Beneficial Ownership (Instr.
5)
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Common Stock |
0 |
D |
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Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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1. Title of Derivative Security (Instr.
4)
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2. Date Exercisable and Expiration Date
(Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr.
4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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6. Nature of Indirect Beneficial Ownership (Instr.
5)
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Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
Explanation of Responses: |
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/s/ Paul F. Hickey |
08/26/2022 |
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** 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
5
(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
PAUL F. HICKEY
With respect to holdings of and transactions in securities
issued by ReShape Lifesciences Inc. (the Company), the
undersigned hereby constitutes and appoints the officers
of the Company listed on Schedule A attached hereto and as
may be amended from time to time, or any of them signing
singly, with full power of substitution and resubstitution,
to act as the undersigned's true and lawful attorney-in-fact
to:
1. prepare, execute in the undersigned's name and
on the undersigned's behalf, and submit to the United
States Securities and Exchange Commission (the SEC) a
Form ID, including amendments thereto, and any other
documents necessary or appropriate to obtain and/or
regenerate codes and passwords enabling the undersigned
to make electronic filings with the SEC of reports
required by Section 16(a) of the Securities Exchange Act
of 1934, as amended, Rule 144 under the Securities Act
of 1933, as amended, or any rule or regulation of the SEC;
2. execute for and on behalf of the undersigned,
Forms 3, 4, and 5 in accordance with Section 16 of the
Securities Exchange Act of 1934, as amended, or any
Form 144 in accordance with Rule 144 under the Securities
Act of 1933, as amended, and the rules and regulations
thereunder;
3. do and perform any and all acts for and on
behalf of the undersigned which may be necessary or
desirable to complete and execute any such Form 3, 4,
or 5 or Form 144 or complete and execute any amendment
or amendments thereto, and timely file such forms with
the SEC and any stock exchange or similar authority; and
4. take any other action of any type whatsoever
in connection with the foregoing which, in the opinion
of such attorney-in-fact, may be of benefit to, in the
best interest of, or legally required by, the undersigned,
it being understood that the documents executed by such
attorney-in-fact on behalf of the undersigned pursuant
to this Power of Attorney shall be in such form and
shall contain such terms and conditions as such attorney-
in-fact may approve in the discretion of such attorney-
in-fact.
The undersigned hereby grants to each such attorney-in-fact
full power and authority to do and perform any and every
act and thing whatsoever requisite, necessary, or proper
to be done in the exercise of any of the rights and powers
herein granted, as fully to all intents and purposes as
the undersigned might or could do if personally present,
with full power of substitution and resubstitution or
revocation, hereby ratifying and confirming all that
such attorney-in-fact, or such attorney-in-facts substitute
or substitutes, shall lawfully do or cause to be done by
virtue of this Power of Attorney and the rights and powers
herein granted.
The undersigned hereby acknowledges that the
attorneys-in-fact, in serving in such capacity at the
request of the undersigned, are not assuming, nor is
the Company assuming, any of the undersigned's
responsibilities to comply with Section 16 of the
Securities Exchange Act of 1934, as amended, or Rule
144 of the Securities Act of 1933, as amended, and
any similar law, rule or regulation.
This Power of Attorney shall remain in full force and
effect until the undersigned is no longer required to
file Forms 3, 4, and 5 and Forms 144 with respect to
the undersigned's holdings of and transactions in
securities issued by the Company, unless earlier
revoked by the undersigned in a signed writing
delivered to the foregoing attorneys-in-fact.
IN WITNESS WHEREOF, the undersigned has caused this
Power of Attorney to be executed as of this 26th day
of August 2022.
/s/ Paul F. Hickey
Paul F. Hickey
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Shedule A
Individuals Appointed as Attorney-in-Fact with Full Power
of Substitution and Resubstitution
1. Thomas Stankovich, Chief Financial Officer