Filing Details
- Accession Number:
- 0001185185-18-000955
- Form Type:
- 13D Filing
- Publication Date:
- 2018-05-18 14:39:09
- Filed By:
- Kubota Tom
- Company:
- Pacific Health Care Organization Inc (OTCMKTS:PFHO)
- Filing Date:
- 2018-05-18
- SEC Url:
- 13D Filing
Ownership Summary
Please notice the below summary table is generated without human intervention and may contain errors. Please refer to the complete filing displayed below for exact figures.
| Name | Sole Voting Power | Shared Voting Power | Sole Dispositive Power | Shared Dispositive Power | Aggregate Amount Owned Power | Percent of Class |
|---|---|---|---|---|---|---|
| Tom Kubota | 1,949,500 | 60.8% |
Filing
| UNITED STATES |
| SECURITIES AND EXCHANGE COMMISSION |
| Washington, D.C. 20549 |
| SCHEDULE 13D/A |
| Under the Securities Exchange Act of 1934 |
| (Amendment No. 16) |
| Pacific Health Care Organization, Inc. | ||
| (Name of Issuer) | ||
| Common Stock, $.001 par value per share | ||
| (Title of Class of Securities) | ||
| 69439P308 | ||
| (CUSIP Number) |
| Tom Kubota | ||
| 2618 San Miguel Drive, #477 | ||
| Newport Beach, California 92660 | ||
| (949) 721-8272 | ||
| (Name, Address and Telephone Number of Person Authorized to | ||
| Receive Notes and Communications) |
| May 16, 2018 | ||
| (Date of Event which Requires Filing of this Statement) |
If the filing person has previously filed a statement on Schedule 13G to report the acquisition which is the subject of this Schedule 13D, and is filing this schedule because of Rule 13d-1(e), 13d-1(f) or 13d-1(g), check the following box. ☐
* The remainder of this cover page shall be filled out for a reporting person’s initial filing on this form with respect to the subject class of securities, and for any subsequent amendment containing information which would alter the disclosures provided in a prior cover page.
The information required in the remainder of this cover page shall not be deemed to be “filed” for the purpose of Section 18 of the Securities Exchange Act of 1934 (“Act”) or otherwise subject to the liabilities of that section of the Act but shall be subject to all other provisions of the Act (however, see the Notes).
CUSIP No. 69439P308
| 1. | Names of Reporting Persons | ||||||
| Tom Kubota | |||||||
| 2. | Check the Appropriate Box if a Member of a Group (See Instructions) | ||||||
| (a) ☐ | |||||||
| (b) ☐ | |||||||
| 3. | SEC Use Only | ||||||
| 4. | Source of Funds (See Instructions) | ||||||
| PF | |||||||
| 5. | Check if Disclosure of Legal Proceedings is Required Pursuant to Items 2(d) or 2(e) | ☐ | |||||
| 6. | Citizenship or Place of Organization | ||||||
| United States of America | |||||||
| Number of | 7. | Sole Voting Power | |||||
| Shares | 1,949,500(1)(2) | ||||||
| Beneficially | 8. | Shared Voting Power | |||||
| Owned by | -0- | ||||||
| Each | 9. | Sole Dispositive Power | |||||
| Reporting | 1,949,500(1)(2) | ||||||
| Person | 10. | Shared Dispositive Power | |||||
| With | -0- | ||||||
| 11. | Aggregate Amount Beneficially Owned by Each Reporting Person | ||||||
| 1,949,500(1)(2) | |||||||
| 12. | Check if the Aggregate Amount in Row (11) Excludes Certain Shares (See Instructions) | ☐ | |||||
| 13. | Percent of Class Represented by Amount in Row (11) | ||||||
| 60.8% | |||||||
| 14. | Type of Reporting Person (See Instructions) | ||||||
| IN | |||||||
(1) Includes 1,945,500 shares of the Issuer’s Common Stock and 4,000 shares of the Issuer’s Series A Preferred Stock owned by the Reporting Person. The Series A Preferred Stock is convertible to Common Stock of the Issuer on a one-share for one-share basis, based on the number of shares of Series A Preferred Stock converted and not the number of votes represented by such converted shares of Series A Preferred Stock. The Series A Preferred Stock is convertible only by the holder thereof and is convertible at any time. Each outstanding share of Series A Preferred Stock is entitled to vote as 20,000 shares of Common Stock. In August 2017, the Reporting Person was awarded stock options to purchase 200,000* shares of Common Stock of the Issuer, subject to certain vesting conditions. On May 14, 2018, the Reporting Person agreed to the surrender and cancellation of these stock options (the “Cancelled Options”) without any expectation to receive, and without any obligation on the Issuer to pay or grant, any cash, equity awards or other consideration presently or in the future with respect to the Cancelled Options. As the Cancelled Options have been cancelled, the shares underlying the Cancelled Options are not included herein.
* Adjusted to reflect the four-shares-for-one-share forward split of the Company’s Common Stock effected April 5, 2017.
(2) These shares are held in the name of the Tom Kubota Revocable Trust of 2013 (the “Trust”). The Reporting Person is the sole Trustee of the Trust and may be deemed to have voting and dispositive power over the shares held by the Trust.
EXPLANATORY NOTE
This Amendment No. 16 (“Amendment No. 16”), dated May 16, 2018, amends and supplements the original Schedule 13D filed by the Reporting Person with the Securities and Exchange Commission (the “Commission”) on June 27, 2008, relating to shares of Common Stock, $0.001 par value per share (“Common Stock”) of Pacific Health Care Organization, Inc. (the “Issuer”), as amended and supplemented by Schedules 13D/A-1 filed on August 28, 2008, Schedule 13D/A-2 filed on May 14, 2010, Schedule 13D/A-3 filed on May 14, 2010, Schedule 13D/A-4 filed on April 20, 2012, Schedule 13D/A-5 filed on May 21, 2013, Schedule 13D/A-6 filed March 12, 2014, Schedule 13D/A-7 filed April 30, 2014, Schedule 13D/A-8 filed on June 10, 2014, Schedule 13D/A-9 filed on June 17, 2014, Schedule 13D/A-10 filed on March 31, 2015, Schedule 13D/A-11 filed on November 16, 2015, Schedule 13D/A-12 filed on November 18, 2015, and Schedule 13D/A-13 filed on December 1, 2016, Schedule 13d/A-14 filed on January 10, 2018 and Schedule 13d/A-15 filed on May 1, 2018 (collectively referred to herein as the “Schedule 13D”). Only those items hereby reported in this Amendment No. 16 are amended and all other items remain unchanged. Terms used herein but not otherwise defined shall have the meanings set forth in the Schedule 13D.
Item 3. Source and Amount of Funds or Other Consideration
Item 3 of the Schedule 13D is hereby amended and supplemented as follows:
The Reporting Person used $2,375.00 of personal funds to purchase 500 shares of the Issuer in the open market.
Item 4. Purpose of Transaction
Item 4 of the Schedule 13D is hereby amended and restated as follows:
The acquisition described herein was not for the purpose of changing control of the Issuer. Prior to and following the acquisition described herein, the Reporting Person was and continues to be the Chief Executive Officer and President and Chairman of the board of directors (the “Board”) of the Issuer. Prior to the acquisition, the Reporting Person was the single largest holder of Common Stock of the Issuer, owning approximately 60.8% of the outstanding Common Stock of the Issuer. The Reporting Person made the acquisition outlined in Item 3 above because the shares were available for sale and he chose to acquire them. The Reporting Person did not make the acquisition described herein with intent to or for the purpose of effecting any of the transactions described in subparagraphs (a) through (j) of Item 4 of Schedule 13D. The Reporting Person may, at any time, review or reconsider his position with respect to the Issuer and formulate plans or proposals with respect to any of the matters described in subparagraphs (a) through (j) of Item 4 of Schedule 13D.
Item 5. Interest in Securities of the Issuer
Item 5 of Schedule 13D is hereby amended and restated as follows:
(a) Through the Trust the Reporting Person beneficially owns 1,945,500 shares of Common Stock and 4,000 shares of Series A Preferred Stock of the Issuer. Assuming conversion of the 4,000 shares of Series A Preferred Stock by the Reporting Person into 4,000 shares of Common Stock as of May 16, 2018, the Reporting Person would beneficially own approximately 60.8% of the Issuer’s Common Stock, as disclosed in the Quarterly Report on Form 10-Q of the Issuer filed May 15, 2017.
(b) As sole Trustee of the Trust, the Reporting Person has the sole power to vote or direct the vote of all shares held by the Trust.
(c) Other than as disclosed herein and in Schedule 13d/A-15 filed by the Reporting Person on May 1, 2018, the Reporting Person has not engaged in any transactions in the Common Stock of the Issuer in the past 60 days.
(d) No other person is known to have the right to receive or the power to direct the receipt of dividends from, or the proceeds from the sale of, the shares held by the Reporting Person.
(e) Not Applicable.
SIGNATURES
After reasonable inquiry and to the best of my knowledge and belief, I certify that the information set forth in this statement is true, complete and correct.
| Date: May 18, 2018 | By: | /s/ Tom Kubota |
| Tom Kubota |