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
|
| 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)
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Director |
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10% Owner |
| X |
Officer (give title below) |
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Other (specify below) |
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Chief Growth Officer
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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 |
129,206 |
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 |
|
|
Common Shares |
510,205 |
|
D |
|
| Restricted Stock Units |
|
|
Common Shares |
164,327 |
|
D |
|
| Restricted Stock Units |
|
|
Common Shares |
103,834 |
|
D |
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| Explanation of Responses: |
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| Remarks: |
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/s/ David Sirolly as attorney-in-fact for Jesse Channon |
02/14/2022 |
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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
(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 such 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 4th day of February, 2022.
/s/ Jesse Channon
