Initial Statement of Beneficial Ownership (3)
20 Décembre 2021 - 11:13PM
Edgar (US Regulatory)
FORM 3
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0104
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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
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Rodriguez Manuel Antonio |
2. Date of Event Requiring Statement (MM/DD/YYYY)
12/10/2021
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3. Issuer Name and Ticker or Trading Symbol
BASANITE, INC. [BASA]
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(Last)
(First)
(Middle)
C/O BASANITE, INC., 2041 NW 15TH AVENUE |
4. 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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(Street)
POMPANO BEACH, FL 33069
(City)
(State)
(Zip)
| 5. If Amendment, Date Original Filed(MM/DD/YYYY)
| 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 Beneficially Owned
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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 | 10000 | D | |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security (Instr. 4) | 2. Date Exercisable and Expiration Date (MM/DD/YYYY) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form of Derivative Security: 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 |
Warrant | 12/10/2021 | 12/10/2026 | Restricted Common Stock | 20000000 | $0.33 | I | U.S. Supplies Inc. (1) |
Explanation of Responses: |
(1) | Manuel A. Rodriguez ("Mr. Rodriguez") is the President of U.S. Supplies, Inc. ("U.S. Supplies"). On December 10, 2021, in connection with certain agreements entered into between U.S. Supplies and Basanite, Inc. (the "Company"), U.S. Supplies was issued a warrant (the "Warrant") to purchase up to forty million (40,000,000) shares of restricted common stock of the Company beginning on December 10, 2021 and expiring on December 10, 2026. The right to purchase fifty percent (50%) of such shares (or 20,000,000 shares) vested on the grant date and the right to purchase the remaining fifty percent (50%) of such shares (or 20,000,000 shares) vests upon the satisfaction of a condition precedent as detailed in the Warrant. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Rodriguez Manuel Antonio C/O BASANITE, INC. 2041 NW 15TH AVENUE POMPANO BEACH, FL 33069 | X |
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Signatures
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/s/ Manuel A. Rodriquez | | 12/20/2021 |
**Signature of Reporting Person | Date |
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