Sec Form 4 Filing - LORD JONATHAN T MD @ BIOLASE, INC - 2022-04-28

Insider filing report for Changes in Beneficial Ownership
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FORM 4
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
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, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person
LORD JONATHAN T MD
2. Issuer Name and Ticker or Trading Symbol
BIOLASE, INC [ BIOL]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X __ Director _____ 10% Owner
_____ Officer (give title below) _____ Other (specify below)
(Last) (First) (Middle)
27042 TOWNE CENTRE DR., SUITE 270
3. Date of Earliest Transaction (MM/DD/YY)
04/28/2022
(Street)
FOOTHILL RANCH, CA92610
4. If Amendment, Date Original Filed (MM/DD/YY)
6. Individual or Joint/Group Filing (Check Applicable Line)
__ X __ Form filed by One Reporting Person
_____ Form filed by More than One Reporting Person
(City) (State) (Zip)
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1.Title of Security
(Instr. 3)
2. Transaction Date (MM/DD/YY) 2A. Deemed Execution Date, if any (MM/DD/YY) 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
Series G Preferred Stock 04/28/2022 D 1,395.41( 1 )( 2 ) D 0 D
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 (MM/DD/YY) 3A. Deemed Execution Date, if any (MM/DD/YY) 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
(MM/DD/YY)
7. Title and Amount of Underlying Securities
(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 of Derivative Security: 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
Reporting Owners
Reporting Owner Name / Address Relationships
Director 10% Owner Officer Other
LORD JONATHAN T MD
27042 TOWNE CENTRE DR.
SUITE 2 70
FOOTHILL RANCH, CA92610
X
Signatures
/s/ Michael C. Carroll, attorney-in-fact for Jonathan T. Lord 05/02/2022
Signature of Reporting Person Date
Explanation of Responses:
( 1 )On March 1, 2022, the Company's board of directors (the "Board") declared a dividend of one one-thousandth of a share of Series G Preferred Stock, par value $0.001 per share ("Preferred Stock"), for each outstanding share of Company Common Stock to stockholders of record at 5:00 p.m. Eastern Time on March 25, 2022 (the "Record Date"), in a transaction exempt from Section 16 under Rule 16a-9. The shares of Preferred Stock were distributed on March 25, 2022. As a result, the Reporting Person received 1,395.41 shares of Preferred Stock. The Preferred Stock is not convertible into, or exchangeable for, shares of any other class or series of stock or other securities of the Company.
( 2 )On April 28, 2022, these shares of Preferred Stock were redeemed automatically in accordance with the certificate of designation for the shares of Preferred Stock. Each share of Preferred Stock was redeemed in consideration for the right to receive an amount equal to $0.01 in cash for each ten whole shares of Preferred Stock, with any remaining shares (of less than 10) receiving no cash.

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).
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