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*
MATHIESEN JEFFREY S

(Last) (First) (Middle)
C/O HELIUS MEDICAL TECHNOLOGIES, INC.
642 NEWTOWN YARDLEY ROAD, SUITE 100

(Street)
NEWTOWN PA 18940

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
06/10/2020
3. Issuer Name and Ticker or Trading Symbol
HELIUS MEDICAL TECHNOLOGIES, INC. [ HSDT ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director 10% Owner
Officer (give title below) Other (specify below)
5. If Amendment, Date of Original Filed (Month/Day/Year)
06/12/2020
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
Stock Option (Right to Buy) (1) 06/09/2030 Class A Common Stock 61,218(2) 0.545 D
Explanation of Responses:
1. Grant to the Reporting Person of a stock option under the Issuer's 2018 Omnibus Incentive Plan. The shares vest in a series of twelve (12) successive equal monthly installments measured from June 10, 2020, subject to the Reporting Person's continued service through each applicable vesting date.
2. This Form 3/A is being filed to amend an inadvertent error in the number of stock options granted to the Reporting Person in the Form 3 previously filed on June 12, 2020. The number of stock options reported on this amendment reflect the correct number of stock options granted to the Reporting Person.
Remarks:
/s/ Philippe Deschamps, Attorney-in-Fact 06/16/2020
** 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.