SOURCE: Medical Alarm Concepts Holding, Inc

Medical Alarm Concepts Holding, Inc - FORM D

SUGGESTED

You may not send a completed printout of this form to the SEC to satisfy a filing obligation. You can only satisfy an SEC filing obligation by submitting the information required by this form to the SEC in electronic format online at https://www.onlineforms.edgarfiling.sec.gov.

 

FORM D

Notice of Exempt
Offering of Securities

 

U.S. Securities and Exchange Commission

Washington, DC 20549

 

(See instructions beginning on page 5)

 

OMB APPROVAL

OMB Number: 3235-0076

Expires: August 31, 2015

Estimated average burden
hours per response: 4.00

Intentional misstatements or omissions of fact constitute federal criminal violations. See 18 U.S.C. 1001.

Item 1. Issuer's Identity

 

Name of Issuer

 

Previous Name(s)              X None

 

Entity Type (Select one)

X Corporation

Limited Partnership

Limited Liability Company

General Partnership

Business Trust

Other (Specify)

Medical Alarm Concepts Holding, Inc.

 

     

 

     

 

     

 

 

Jurisdiction of Incorporation/Organization

 

 

Nevada

 

 

Year of Incorporation/Organization

(Select one)

 

 

Over Five Years Ago

X Within Last Five Years
(specify year)

     

Yet to Be Formed

 

 

 

     

 

(If more than one issuer is filing this notice, check this box and identify additional issuer(s) by attaching Items 1 and 2 Continuation Page(s).)

 

 

Item 2. Principal Place of Business and Contact Information

 

Street Address 1

Street Address 2

200 West Church Road

 

Suite B

 

City

State/Province/Country

ZIP/Postal Code

Phone No.

King of Prussia

 

PA

 

19406

 

877-498-2929

 

Item 3. Related Persons

 

Last Name

First Name

Middle Name

Adams

 

Ronnie

 

     

 

Street Address 1

Street Address 2

200 West Church Road

 

Suite B

 

City

State/Province/Countr

ZIP/Postal Code

King of Prussia

 

PA

 

19406

 

 

Relationship(s):              X Executive Officer              X Director              Promoter

 

Clarification of Response (if Necessary)

     

(Identify additional related persons by checking this box X and attaching Item 3 Continuation Page(s). )

 

Item 4. Industry Group     (Select one)

   Agriculture
Banking and Financial Services

Commercial Banking

Insurance

Investing

Investment Banking

Pooled Investment Fund

If selecting this industry group, also select one fund type below and answer the question below:

Hedge Fund

Private Equity Fund

Venture Capital Fund

Other Investment Fund

Is the issuer registered as an investment
company under the Investment Company
Act of 1940?    Yes   No 

Other Banking & Financial Services

Business Services
Energy

Electric Utilities

Energy Conservation

Coal Mining

Environmental Services

Oil & Gas

Other Energy

    Health Care

Biotechnology

Health Insurance

Hospitals & Physicians

Pharmaceuticals

Other Health Care

Manufacturing
Real Estate

Commercial

Construction

REITS & Finance

Residential

Other Real Estate

Retailing

Restaurants

     Technology

Computers

Telecommunications

Other Technology

     Travel

Airlines & Airports

Lodging & Conventions

Tourism & Travel Services

Other Travel

X Other


 

FORM D

U.S. Securities and Exchange Commission

Washington, DC 20549

 

Item 5. Issuer Size      (Select one)

 

Revenue Range (for issuer not specifying "hedge”
or "other investment" fund in Item 4 above)

 

 

OR

Aggregate Net Asset Value Range (for issuer
specifying "hedge" or "other investment" fund in
Item 4 above)

No Revenues

$1 - $1,000,000

X $1,000,001 - $5,000,000

$5,000,001 - $25,000,000

$25,000,001 - $100,000,000

Over $100,000,000

Decline to Disclose

Not Applicable

No Aggregate Net Asset Value

$1 - $5,000,000

$5,000,001 - $25,000,000

$25,000,001 - $50,000,000

$50,000,001 - $100,000,000

Over $100,000,000

Decline to Disclose

Not Applicable

Item 6. Federal Exemptions and Exclusions Claimed      (Select all that apply)

Investment Company Act Section 3(c)

Rule 504(b)(1) (not (i), (ii) or (iii))

Rule 504(b)(1)(i)

Rule 504(b)(1)(ii)

Rule 504(b)(1)(iii)

Rule 505

X Rule 506

Securities Act Section 4(5)

Section 3(c)(1)

Section 3(c)(2)

Section 3(c)(3)

Section 3(c)(4)

Section 3(c)(5)

Section 3(c)(6)

Section 3(c)(7)

Section 3(c)(9)

Section 3(c)(10)

Section 3(c)(11)

Section 3(c)(12)

Section 3(c)(13)

Section 3(c)(14)

 

Item 7. Type of Filing

X New Notice               OR               Amendment

 

Date of First Sale in this Offering:

09/02/11

OR

  First Sale Yet to Occur

 

Item 8. Duration of Offering

Does the issuer intend this offering to last more than one year?               Yes     X No

 

Item 9. Type(s) of Securities Offered      (Select all that apply)

 

              Equity

X              Debt

              Option, Warrant or Other Right to Acquire
Another Security

              Security to be Acquired Upon Exercise of Option,
Warrant or Other Right to Acquire Security

Pooled Investment Fund Interests

Tenant-in-Common Securities

Mineral Property Securities

Other (Describe)

     

Item 10. Business Combination Transaction

Is this offering being made in connection with a business combination
transaction, such as a merger, acquisition or exchange offer?              Yes     X No

 

Clarification of Response (if Necessary)

     

 

 

FORM D

U.S. Securities and Exchange Commission

Washington, DC 20549

 

Item 11. Minimum Investment

 

Minimum investment accepted from any outside investor            $

$100.00

 

Item 12. Sales Compensation

Recipient

Recipient CRD Number

 

None

 

     

 

No CRD Number

 

(Associated) Broker or Dealer                 None

(Associated) Broker or Dealer CRD Number

 

     

 

     

 

No CRD Number

 

Street Address 1

Street Address 2

     

 

     

 

City

State/Province/Country

ZIP/Postal Code

 

     

 

     

 

     

 

 

States of Solicitation               All States

AL

AK

AZ

AR

X

CA

CO

CT

DE

DC

FL

GA

HI

ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IL

IN

IA

KS

KY

LA

ME

MD

MA

MI

MN

MS

MO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MT

NE

NV

NH

NJ

NM

NY

NC

ND

OH

OK

OR

PA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RI

SC

SD

TN

TX

UT

VT

VA

WA

WV

WI

WY

PR

(Identify additional person(s) being paid compensation by checking this box and attaching Item 12 Continuation Page(s).)

 

Item 13. Offering and Sales Amounts

 

(a) Total Offering Amount

$

121,750.00

OR            Indefinite

 

(b) Total Amount Sold

$

121,750.00

 

 

(c) Total Remaining to be Sold
       (Subtract (a) from (b))

$

0

OR            Indefinite

 

Clarification of Response (if Necessary)

 

 

 

Item 14. Investors

 

Check this box _____ if securities in the offering have been or may be sold to persons who do not qualify as accredited investors, and enter the number of such non-accredited investors who already have invested in the offering:

 

0

 

 

Enter the total number of investors who already have invested in the offering:

1

 

 

Item 15. Sales Commissions and Finders' Fees Expenses

 

Provide separately the amounts of sales commissions and finders' fees expenses, if any. If an amount is not known, provide an estimate and check the box next to the amount.

Sales Commissions $

0

Estimate

 

Finders' Fees $

0

Estimate

Clarification of Response (if Necessary)

     

 

 

 

FORM D

U.S. Securities and Exchange Commission

Washington, DC 20549

 

Item 16. Use of Proceeds

 

Provide the amount of the gross proceeds of the offering that has been or is proposed to be  used for payments to any of the persons required to be named as executive officers, directors or promoters in response to Item 3 above. If the amount is unknown, provide an  estimate and check the box next to the amount.

$

0

Estimate

 

 

 

Clarification of Response (if Necessary)

     

 

Signature and Submission

 

Please verify the information you have entered and review the Terms of Submission below before signing and submitting this notice.

 

Terms of Submission. In Submitting this notice, each identified issuer is:

 

              Notifying the SEC and/or each State in which this notice is filed of the offering of securities described and
undertaking to furnish them, upon written request, in accordance with applicable law, the information furnished to offerees.*

              Irrevocably appointing each of the Secretary of the SEC and the Securities Administrator or other legally designated officer of the State in which the issuer maintains its principal place of business and any State in which this notice is filed, as its agents for service of  process, and agreeing that these persons may accept service on its behalf, of any notice, process or pleading, and further agreeing that such service may be made by registered or certified mail, in any Federal or state action, administrative proceeding, or arbitration brought against the issuer in any place subject to the jurisdiction of the United States, if the action, proceeding or arbitration (a) arises out of any activity in connection with the offering of securities that is the subject of this notice, and (b) is founded, directly or indirectly, upon the provisions of: (i) the Securities Act of 1933, the Securities Exchange Act of 1934, the Trust Indenture Act of 1939, the Investment Company Act of 1940, or the Investment Advisers Act of 1940, or any rule or regulation under any of these statutes; or (ii) the laws of the State in which the issuer maintains its principal place of business or any State in which this notice is filed.

              Certifying that, if the issuer is claiming a Rule 505 exemption, the issuer is not disqualified from relying on Rule 505 for one of the reasons stated in Rule 505(b)(2)(iii).

?          This undertaking does not affect any limits Section 102(a) of the National Securities Markets Improvement Act of 1996 ("NSMIA") [Pub. L. No. 104-290,110 Stat. 3416 (Oct. 11, 1996)] imposes on the ability of States to require information. As a result, if the securities that are the subject of this Form D are “covered securities" for purposes of NSMIA, whether in all instances or due to the nature of the offering that is the subject of this Form D, States cannot routinely require offering materials under this undertaking or otherwise and can require offering materials only to the extent NSMIA permits them to do so under NSMIA's preservation of their anti-fraud authority.

 

 

 

 

 

Each identified issuer has read this notice, knows the contents to be true, and has duly caused this notice to be signed on its behalf by the undersigned duly authorized person. (Check this box and attach Signature Continuation Pages for signatures of issuers identified in Item 1 above but not represented by signer below.)

 

Issuer(s)

Name of Signer

Medical Alarm Concepts Holding, Inc.

 

Ronnie Adams

 

Signature

Title

/s/ Ronnie Adams

 

CEO/Director

 

 

 

Date

Number of continuation pages attached:

1

 

01/27/13

 

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.


 

FORM D

U.S. Securities and Exchange Commission

Washington, DC 20549

 

Item 3 Continuation Page

 

 

Item 3. Related Persons (Continued)

 

Last Name

First Name

Middle Name

Polsky

 

Alan

 

     

 

Street Address 1

Street Address 2

200 West Church Road

 

Suite B

 

City

State/Province/Countr

ZIP/Postal Code

King of Prussia

 

PA

 

19406

 

x

Relationship(s):              Executive Officer              X Director              Promoter

 

Clarification of Response (if Necessary)

     

 

 

Last Name

First Name

Middle Name

     

 

     

 

     

 

Street Address 1

Street Address 2

     

 

     

 

City

State/Province/Country

ZIP/Postal Code

     

 

     

 

     

 

 

Relationship(s):              Executive Officer              Director              Promoter

 

Clarification of Response (if Necessary)

     

 

 

Last Name

First Name

Middle Name

     

 

     

 

     

 

Street Address 1

Street Address 2

     

 

     

 

City

State/Province/Country

ZIP/Postal Code

     

 

     

 

     

 

 

Relationship(s):              Executive Officer              Director              Promoter

 

Clarification of Response (if Necessary)

     

 

 

Last Name

First Name

Middle Name

     

 

     

 

     

 

Street Address 1

Street Address 2

     

 

     

 

City

State/Province/Country

ZIP/Postal Code

     

 

     

 

     

 

 

Relationship(s):              Executive Officer              Director              Promoter

 

Clarification of Response (if Necessary)

     

 

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