SEC Form 5
FORM 5 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

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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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
  
Form 3 Holdings Reported.
X
Form 4 Transactions Reported.
1. Name and Address of Reporting Person*
Simpson Tom

(Last) (First) (Middle)
2818 N. SULLIVAN ROAD

(Street)
SPOKANE WA 99216

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
Kaspien Holdings Inc. [ KSPN ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director 10% Owner
Officer (give title below) Other (specify below)
3. Statement for Issuer's Fiscal Year Ended (Month/Day/Year)
01/30/2021
4. If Amendment, Date of Original Filed (Month/Day/Year)
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 Acquired, Disposed of, or Beneficially Owned
1. Title of Security (Instr. 3) 2. Transaction Date (Month/Day/Year) 2A. Deemed Execution Date, if any (Month/Day/Year) 3. Transaction Code (Instr. 8) 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) 5. Amount of Securities Beneficially Owned at end of Issuer's Fiscal Year (Instr. 3 and 4) 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 7. Nature of Indirect Beneficial Ownership (Instr. 4)
Amount (A) or (D) Price
Common stock, par value $0.1 per share 11/25/2020 X4 12,593 A $0.01 12,593 I By Kick Start III, LLC(2)
Common stock, par value $0.1 per share 11/25/2020 X4 8,395 A $0.01 8,395 I By Kick Start IV, LLC(3)
Common Stock, par value $.01 per share 57,000 D
Common stock, par value $.01 per share 23,879 I By WIN Partners(4)
Common Stock, par value $.01 per share 9,737 I By Kick Start, LLC(1)
Common stock, par value $.01 per share 25 I By Wife
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 (Month/Day/Year) 3A. Deemed Execution Date, if any (Month/Day/Year) 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 (Month/Day/Year) 7. Title and Amount of Securities Underlying Derivative Security (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: Direct (D) or Indirect (I) (Instr. 4) 11. Nature of Indirect Beneficial Ownership (Instr. 4)
(A) (D) Date Exercisable Expiration Date Title Amount or Number of Shares
Warrant to purchase Common Stock, par value $0.01 per share $0.01 11/25/2020 4X 12,593 03/30/2020 03/30/2025 Common Stock, par value $0.01 per share 12,593 $0 1,448 I By Kick Start III, LLC(2)
Warrant to purchase Common Stock, par value $0.01 per share $0.01 11/25/2020 4X 8,395 03/30/2020 03/30/2025 Common Stock, par value $0.01 per share 8,395 $0 965 I By Kick Start IV,LLC(3)
Explanation of Responses:
1. Securities held by Kick Start, LLC. Mr. Simpson holds an interest, manages and has voting control of Kick Start, LLC.
2. Securities held by Kick Start III, LLC. Mr. Simpson holds an interest, manages and has voting control of Kick Start III.
3. Securities held by Kick Start IV, LLC. Mr. Simpson holds an interest, manages and has voting control of Kick Start IV, LLC.
4. Securities held by WIN Partners. Mr. Simpson holds an interest, manages and has voting control of WIN Partners.
Tom Simpson 03/08/2021
** 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 4 (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.