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 COLUMBIA CARE INC. |
680 FIFTH AVENUE, 24TH FLOOR |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 02/14/2022
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3. Issuer Name and Ticker or Trading Symbol
Columbia Care Inc.
[ CCHW ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X |
Director |
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10% Owner |
X |
Officer (give title below) |
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Other (specify below) |
Executive Chairman
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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 Shares |
321,151 |
D |
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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 |
Restricted Stock Units |
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Common Shares |
217,673 |
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D |
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Restricted Stock Units |
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Common Shares |
102,478 |
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D |
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Restricted Stock Units |
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Common Shares |
479,284 |
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D |
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Restricted Stock Units |
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Common Shares |
225,320 |
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D |
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Performance Stock Units |
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04/29/2022 |
Common Shares |
870,691 |
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D |
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Performance Stock Units |
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04/29/2024 |
Common Shares |
870,691 |
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D |
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Explanation of Responses: |
Remarks: |
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/s/ David Sirolly as attorney-in-fact for Michael Abbott |
03/30/2022 |
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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. |
LIMITED POWER OF ATTORNEY FOR REPORTING
UNDER SECTION 16(a) OF THE SECURITIES EXCHANGE
ACT OF 1934, AS AMENDED
POWER OF ATTORNEY
Know all by these presents, that the undersigned hereby constitutes and appoints
David Sirolly and Jonathan Gothorpe, each acting individually, as the undersigned's
true and lawful attorney-in-fact to:
(1) execute for and on behalf of the undersigned, in the undersigned's capacity
as a director or officer of Columbia Care Inc., a British Columbia corporation
("Columbia Care"), Forms 3, 4 and 5 in accordance with Section 16(a)
of the Securities Exchange Act of 1934, as amended (the "Exchange Act"), and the rules
and regulations of the United States Securities and Exchange Commission (the "SEC")
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 and execute any such Forms 3, 4 and 5,
complete and execute any amendment or amendments thereto, and to timely file any
such form with the SEC and any stock exchange or similar authority, including
completing and executing a Uniform Application for Access Codes to File on
Edgar on Form ID; and and application with the United States Securites and
Exchange Commmission and any stock exchange or similar authority, including
completing and executing a Uniform Applicaiton for Access Codes to File on
Edgar on Form ID; 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 such attorney-in-fact's discretion.
The undersigned hereby grants to 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 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 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 neither Columbia Care
nor the foregoing attorney-in-fact, in serving in such capacity at the request of the
undersigned, are not assuming any liability for the undersigned's responsibility to
comply with the requirements of Section 13 or Section 16 or the Exchange Act or
Rule 144, any liability of the undersigned for any failure to comply with such
requirements, or any liability of the undersigned for disgorgement of profits
under Section 16(b) of the Exchange Act.
The undersigned agrees that each such attorney-in-fact herein may rely entirely
on information furnished orally or in writing by the undersigned to suc
attorney-in-fact. The undersigned also agrees to indemnify and hold harmless
Columbia Care and such attorney-in-fact against any losses, claims, damages
or liabilities (or actions in these respects) that arise out of or are based
on any untrue statement or omission of necessary facts in the
information provided by the undersigned to such attorney-in-fact for purposes
of executing, acknowledging, delivering and filing Forms 3, 4 or 5 (including
amendments thereto) and agrees to reimburse Columbia Care and such attorney-in-fact
for any legal or other expenses reasonably incurred in connection with investigating
or defending against any such loss, claim, damage, liability or action.
This Power of Attorney supersedes any power of attorney previously executed by
the undersigned regarding the purposes outlined in the first paragraph hereof
("Prior Powers of Attorney"), and the authority of the attorney-in-fact named
in any Prior Powers of Attorney is hereby revoked.
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 Columbia Care, unless
earlier revoked by the undersigned in a signed writing delivered to the foregoing
attorney-in-fact. This Power of Attorney may be filed with the SEC as a
confirming statement of authority granted herein.
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be executed
as of this 2nd day of February, 2022.
/s/ Michael Abbott