SEC FORM 3/A SEC Form 3
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*
Engelson Erik T.

(Last) (First) (Middle)
1412 62ND STREET

(Street)
EMERYVILLE CA 94608

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
02/04/2021
3. Issuer Name and Ticker or Trading Symbol
Lucira Health, Inc. [ LHDX ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director 10% Owner
X Officer (give title below) Other (specify below)
President and Chief Executive
5. If Amendment, Date of Original Filed (Month/Day/Year)
02/04/2021
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 Beneficially Owned
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)
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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
Series B Preferred Stock (1) (1) Common Stock 48,854(2) (1) I See footnote(3)
Explanation of Responses:
1. Each share of Series B Preferred Stock (the "Preferred Stock") automatically converts on a one-for-one basis into Common Stock upon the closing of the Issuer's initial public offering, for no additional consideration. The shares of Preferred Stock have no expiration date.
2. These shares were inadvertently omitted from the Reporting Person's original Form 3, and also were omitted from two Forms 4 filed by the Reporting Person after his original Form 3 was filed.
3. The shares are held by Epic Pacific, LLC, of which Reporting Person is a Member.
Remarks:
/s/ Dan George, Attorney-in-Fact for Erik T. Engelson 03/25/2021
** 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.
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