SEC FORM
3
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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| OMB APPROVAL |
| OMB Number: |
3235-0104 |
| Estimated average burden |
| hours per response: |
0.5 |
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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)
05/01/2023
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3. Issuer Name and Ticker or Trading Symbol
Xtant Medical Holdings, Inc.
[ XTNT ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
| X |
Director |
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10% Owner |
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Officer (give title below) |
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Other (specify below) |
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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)
| X |
Form filed by One Reporting Person |
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Form filed by More than One Reporting Person |
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| Table I - Non-Derivative Securities Beneficially Owned |
|---|
| 1. Title of Security (Instr.
4)
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2.
Amount of Securities Beneficially Owned (Instr.
4)
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3. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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4. Nature of Indirect Beneficial Ownership (Instr.
5)
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| Common Stock, $0.000001 par value |
1,015,272 |
I |
The Platinum Legacy Trust, dated February 24, 2017, Jonn R. Beeson, Trustee |
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)
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2. Date Exercisable and Expiration Date
(Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr.
4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
|
6. Nature of Indirect Beneficial Ownership (Instr.
5)
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| Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
| Warrant |
08/25/2022 |
08/25/2027 |
Common Stock |
253,818 |
0.48 |
I |
The Platinum Legacy Trust, dated February 24, 2017, Jonn R. Beeson, Trustee |
| Explanation of Responses: |
| Remarks: |
|
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/s/ Amy E. Culbert, attorney-in-fact |
05/04/2023 |
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** 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. |
POWER OF ATTORNEY
JONN R. BEESON
With respect to holdings of and transactions in securities
issued by Xtant Medical Holdings, Inc. (the Company), the
undersigned hereby constitutes and appoints the officers
of the Company listed on Schedule A attached hereto and as
may be amended from time to time, or any of them signing
singly, with full power of substitution and resubstitution,
to act as the undersigned's true and lawful attorney-in-fact
to:
1. execute for and on behalf of the undersigned, Forms 3,
4, and 5 in accordance with Section 16 of the United States
Securities Exchange Act of 1934, as amended, and any Form 144
in accordance with Rule 144 under the Securities Act of 1933,
as amended, and the rules and regulations thereunder;
2. do and perform any and all acts for and on behalf
of the undersigned which may be necessary or desirable to
complete and execute any such Form 3, 4, or 5 or Form 144
or complete and execute any amendment or amendments thereto,
and timely file such forms with the United States Securities
and Exchange Commission (the SEC) and any stock exchange or
similar authority; and
3. take any other action of any type whatsoever in
connection with the foregoing which, in the opinion of
such attorney-in-fact, may be of benefit to, in the best
interest of, or legally required by, the undersigned, it
being understood that the documents executed by such
attorney-in-fact on behalf of the undersigned pursuant
to this Power of Attorney shall be in such form and shall
contain such terms and conditions as such attorney-in-fact
may approve in the discretion of such attorney-in-fact.
The undersigned hereby grants to each such attorney-in-fact
full power and authority to do and perform any and every act
and thing whatsoever requisite, necessary, or proper to be
done in the exercise of any of the rights and powers herein
granted, as fully to all intents and purposes as the
undersigned might or could do if personally present, with
full power of substitution and resubstitution or revocation,
hereby ratifying and confirming all that such attorney-in-fact,
or such attorney-in-fact's substitute or substitutes, shall
lawfully do or cause to be done by virtue of this Power of
Attorney and the rights and powers herein granted.
The undersigned hereby acknowledges that the attorneys-in-fact,
in serving in such capacity at the request of the undersigned,
are not assuming, nor is the Company assuming, any of the
undersigned's responsibilities to comply with Section 16 of
the United States Securities Exchange Act of 1934, as amended,
or Rule 144 of the Securities Act of 1933, as amended, and any
similar law, rule or regulation.
This Power of Attorney shall remain in full force and effect
until the undersigned is no longer required to file Forms
3, 4, and 5 and Forms 144 with respect to the undersigned's
holdings of and transactions in securities issued by the
Company, unless earlier revoked by the undersigned in a
signed writing delivered to the foregoing attorneys-in-fact.
IN WITNESS WHEREOF, the undersigned has caused this Power
of Attorney to be executed as of this 1st day of May 2023.
/s/ Jonn R. Beeson
Jonn R. Beeson
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Shedule A
Individuals Appointed as Attorney-in-Fact with Full Power
of Substitution and Resubstitution
1. Sean E. Browne, President and Chief Executive Officer
2. Scott Neils, Chief Financial Officer
3. Stavros Vizirgianakis, Chairman of the Board
4. Amy Culbert, Secretary
5. Thomas Letscher, Assistant Secretary
