Statement of Changes in Beneficial Ownership (4)
01 Août 2019 - 2:48PM
Edgar (US Regulatory)
FORM 4
[
X
]
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b).
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0287
Estimated average burden
hours per response...
0.5
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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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1. Name and Address of Reporting Person
*
Donaldson Richard C
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2. Issuer Name
and
Ticker or Trading Symbol
NESCO HOLDINGS, INC.
[
NSCO
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__
X
__ Director
_____ 10% Owner
_____ Officer (give title below)
_____ Other (specify below)
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(Last)
(First)
(Middle)
C/O CAPITOL INVESTMENT CORP. IV, 1300 17TH STREET, SUITE 820
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3. Date of Earliest Transaction
(MM/DD/YYYY)
7/30/2019
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(Street)
ARLINGTON, VA 20009
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
_
X
_ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security
(Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code
(Instr. 8)
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4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)
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7. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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Amount
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(A) or (D)
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Price
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Common Stock
(1)
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7/30/2019
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C
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38332
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A
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(1)
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38332
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D
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Common Stock
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7/31/2019
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A
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4985
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A
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$10.00
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43317
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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 Derivate Security
(Instr. 3)
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2. Conversion or Exercise Price of Derivative Security
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3. Trans. Date
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3A. Deemed Execution Date, if any
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4. Trans. Code
(Instr. 8)
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5. Number of Derivative Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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6. Date Exercisable and Expiration Date
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7. Title and Amount of Securities Underlying Derivative Security
(Instr. 3 and 4)
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8. Price of Derivative Security
(Instr. 5)
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9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4)
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10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4)
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11. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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(A)
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(D)
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Date Exercisable
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Expiration Date
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Title
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Amount or Number of Shares
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Class B Ordinary Shares
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(1)
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7/30/2019
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D
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11668
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(1)
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(1)
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Common Stock
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11668
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(2)
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38332
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D
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Class B Ordinary Shares
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(1)
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7/30/2019
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C
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38332
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(1)
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(1)
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Common Stock
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38332
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(1)
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0
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D
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Warrants
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$11.50
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7/30/2019
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D
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51020
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(3)
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(4)
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Common Stock
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51020
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(2)
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82313
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D
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Convertible Promissory Note
(6)
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$1.50
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7/31/2019
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C
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$30612.00
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(5)
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(5)
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Warrants
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20408
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(6)
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$0
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D
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Warrants
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$11.50
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7/31/2019
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C
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20408
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(3)
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(4)
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Common Stock
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20408
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$1.50
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102721
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D
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Warrants
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$11.50
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7/31/2019
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S
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20408
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(3)
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(4)
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Common Stock
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20408
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$1.50
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82313
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D
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Explanation of Responses:
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(1)
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The Class B Ordinary Shares were convertible on a one-for-one basis into common equity of the surviving entity upon the consummation of the Issuer's initial business combination and had no exiration date. In connection with the Issuer's business combination, such Class B Ordinary Shares of Capitol Investment Corp. IV automatically converted into shares of common stock of Nesco Holdings, Inc.
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(2)
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The reporting person forfeited these securities to the Issuer for no additional consideration.
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(3)
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The warrants will become exercisable 30 days after the completion of the Issuer's initial business combination.
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(4)
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The warrants will expire on the fifth anniversary of the completion of the Issuer's initial business combination.
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(5)
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The promissory note is convertible, at the reporting person's option, at the closing of the Issuer's initial business combination. If the note is not converted, it will be repaid within 5 business days of the closing of such business combination.
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(6)
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The reporting person was issued a series of convertible promissory notes in consideration of loans made on March 22, 2019, May 15, 2019, and July 24, 2019, in the aggregate principal amount of $30,612.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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Donaldson Richard C
C/O CAPITOL INVESTMENT CORP. IV
1300 17TH STREET, SUITE 820
ARLINGTON, VA 20009
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X
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Signatures
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Richard C. Donaldson
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8/1/2019
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 4(b)(v).
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**
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Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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Note:
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File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure.
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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 control number.
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