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*
| C/O 1 TW ALEXANDER DRIVE |
| SUITE 160 |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
07/22/2021
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3. Issuer Name and Ticker or Trading Symbol
ASENSUS SURGICAL, INC.
[ ASXC ]
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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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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)
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6. Nature of Indirect Beneficial Ownership (Instr.
5)
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| Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
| Explanation of Responses: |
| Remarks: |
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| No securities are beneficially owned. |
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/s/ Joshua Weingard as attorney-in-fact for Elizabeth Kwo |
07/25/2021 |
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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. |
Exhibit 24
POWER OF ATTORNEY
For Executing Forms 3, 4 and 5
Know all persons by these presents, that the undersigned hereby constitutes and
appoints each of Joshua Weingard and Shameze Rampertab, and each or either of
them,
her true and lawful attorney-in-fact to:
(1) prepare and/or execute for and on behalf of the undersigned, in the
undersigned's capacity as an officer of Asensus Surgical, Inc. (the "Company"),
Forms 3, 4 and 5 to report transactions in the Company's securities reportable
by the undersigned in accordance with the provisions of Section 16(a) of the
Securities Exchange Act of 1934, as amended and the rules and regulations
promulgated thereunder;
(2) do and perform any and all acts for and on behalf of the undersigned which
may be necessary or desirable to complete the preparation and execution of any
such Form 3, 4 or 5, and any amendment thereto, and the timely filing of any
such Form 3, 4 or 5, and any amendment thereto, with the United States
Securities and Exchange Commission and any other authority, 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 his or
her discretion; and
(3) resign as attorney-in-fact and appoint, as a replacement attorney-in-fact,
any employee of the Company at the time of such resignation; provided that
such resigning and replacement attorneys-in-fact shall send notice to the
undersigned of any such replacement.
The undersigned hereby grants to each such attorney-in-fact full power and
authority to do and perform all and every act and thing whatsoever requisite,
necessary and 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 or revocation,
hereby ratifying and confirming all that such attorney-in-fact, or any
replacement attorney-in-fact, shall lawfully do or cause to be done by virtue of
this Power of Attorney and the rights and powers herein granted. The
undersigned acknowledges that the foregoing attorneys-in-fact, and any
replacement 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 Securities
Exchange Act of 1934, as amended or the rules and regulations promulgated
thereunder.
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 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 22nd day of July, 2021.
/s/Elizabeth Kwo
Signature
Elizabeth Kwo
Print Name
