| 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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1. Name and Address of Reporting Person*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 01/01/2022 |
3. Issuer Name and Ticker or Trading Symbol
Mind Medicine (MindMed) Inc. [ MNMD ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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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)
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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) |
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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) | 2. Date Exercisable and Expiration Date (Month/Day/Year) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form: 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 | ||||
| Stock Option (Right to Buy) | (1) | 09/29/2031 | Subordinate Voting Shares | 24,442 | 2.38(2) | D | |
| Directors' Deferred Share Units | (3) | (3) | Subordinate Voting Shares | 17,322 | (3) | D | |
| Explanation of Responses: |
| 1. The shares underlying the option shall vest and become exercisable in 12 equal monthly installments beginning on September 29, 2021, subject to the Reporting Person providing continuous service to the Issuer on each such date. |
| 2. The option grant has an exercise price of $3.02 Canadian Dollars. This represents the exercise price in United States Dollars. |
| 3. Represents Directors' Deferred Share Units ("DDSUs") granted pursuant to the Issuer's Directors' Deferred Share Unit Plan (the "Plan"), effective as of April 16, 2021. The DDSUs vest in equal monthly installments over 12 months beginning on September 29, 2021. The DDSUs acquired are to be settled in cash upon the termination of the Reporting Persons' directorship (with each DDSU representing the right to receive the cash equivalent of the fair market value of one Subordinate Voting Share). Pursuant to the Plan, the fair market value of a Subordinate Voting Share is equal to the volume weighted average trading price of a Subordinate Voting Share on the NEO exchange for the five business days immediately preceding the DDSUs vesting date. The DDSUs granted will expire no later than 90 days after the Reporting Person's termination date or such other reasonable time as may be determined by the Administrators (as defined in the Plan). |
| Remarks: |
| No Table I securities beneficially owned Exhibit List - Exhibit 24 - Power of Attorney |
| /s/ Robert Barrow, Attorney-in-Fact | 01/10/2022 | |
| ** 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. | ||