SEC FORM 4 SEC Form 4
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
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*
LOSHITZER ZOHAR

(Last) (First) (Middle)
C/O PRESBIA PLC
120/121 BAGGOT STREET LOWER

(Street)
DUBLIN L2 2

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
Presbia PLC [ LENS ]
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)
03/08/2017
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
Ordinary Shares 03/13/2017 A 12,738(1) A $0 378,960 D
Ordinary Shares 03/08/2017 X 502(2) A $3 2,002 I By Zohar Loshitzer Revocable Trust(4)
Ordinary Shares 03/08/2017 X 670(3) A $3 2,670 I By Dorothea Segal Loshitzer custodian for Oliver Loshitzer UTMA of California(4)
Ordinary Shares 03/08/2017 X 670(5) A $3 2,670 I By Dorothea Segal Loshitzer custodian for Daniel Loshitzer UTMA of California(4)
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
Subscription Rights (Right to Buy) $3 03/08/2017 X 1,498(6) 02/06/2017 03/08/2017 Ordinary Shares 502 $0 0 I By Zohar Loshitzer Revocable Trust(4)
Subscription Rights (Right to Buy) $3 03/08/2017 X 1,999(6) 02/06/2017 03/08/2017 Ordinary Shares 670 $0 0 I By Dorothea Segal Loshitzer custodian for Oliver Loshitzer UTMA of California(4)
Subscription Rights (Right to Buy) $3 03/08/2017 X 1,999(6) 02/06/2017 03/08/2017 Ordinary Shares 670 $0 0 I By Dorothea Segal Loshitzer custodian for Daniel Loshitzer UTMA of California(4)
Explanation of Responses:
1. On March 13, 2017, the Reporting Person was granted 12,738 restricted ordinary shares, which vest on March 13, 2018.
2. On March 8, 2017, the Zohar Loshitzer Revocable Trust delivered to the Issuer an irrevocable notice of exercise of its subscription rights to purchase 502 Ordinary Shares, together with payment of the requisite fee, pursuant to the rights offering set forth in the Prospectus filed pursuant to Rule 424(b)(4), filed with the SEC on January 27, 2017, as amended February 23, 2017.
3. On March 8, 2017, Dorothea Segal Loshitzer custodian for Oliver Loshitzer UTMA of California delivered to the Issuer an irrevocable notice of exercise of her subscription rights to purchase 670 Ordinary Shares, together with payment of the requisite fee, pursuant to the rights offering set forth in the Prospectus filed pursuant to Rule 424(b)(4), filed with the SEC on January 27, 2017, as amended February 23, 2017.
4. The reporting person disclaims beneficial ownership of these securities, and this report shall not be deemed an admission that the reporting person is the beneficial owner of such securities for purposes of Section 16 or for any other purpose.
5. On March 8, 2017, Dorothea Segal Loshitzer custodian for Daniel Loshitzer UTMA of California delivered to the Issuer an irrevocable notice of exercise of her subscription rights to purchase 670 Ordinary Shares, together with payment of the requisite fee, pursuant to the rights offering set forth in the Prospectus filed pursuant to Rule 424(b)(4), filed with the SEC on January 27, 2017, as amended February 23, 2017.
6. Each subscription right entitled its holder to purchase 0.335297256 Ordinary Shares at a subscription price of $3.00 per whole Ordinary Share.
/s/ Zohar Loshitzer 04/13/2017
** 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.