SEC 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
|Estimated average burden|
|hours per response:
1. Name and Address of Reporting Person*
|C/O SALARIUS PHARMACEUTICALS, INC.|
|2450 HOLCOMBE BLVD., SUITE J-608|
2. Date of Event Requiring Statement
3. Issuer Name and Ticker or Trading Symbol
Salarius Pharmaceuticals, Inc.
[ SLRX ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
||Officer (give title below)
||Other (specify below)
5. If Amendment, Date of Original Filed
6. Individual or Joint/Group Filing (Check Applicable Line)
||Form filed by One Reporting Person
||Form filed by More than One Reporting Person
|Table I - Non-Derivative Securities Beneficially Owned|
|1. Title of Security (Instr.
Amount of Securities Beneficially Owned (Instr.
||3. Ownership Form: Direct (D) or Indirect (I) (Instr.
||4. Nature of Indirect Beneficial Ownership (Instr.
Table II - Derivative Securities Beneficially Owned|
(e.g., puts, calls, warrants, options, convertible securities)
|1. Title of Derivative Security (Instr.
||2. Date Exercisable and Expiration Date
||3. Title and Amount of Securities Underlying Derivative Security (Instr.
||4. Conversion or Exercise Price of Derivative Security
||5. Ownership Form: Direct (D) or Indirect (I) (Instr.
||6. Nature of Indirect Beneficial Ownership (Instr.
||Amount or Number of Shares
|Explanation of Responses:|
|No securities are beneficially owned.|
||/s/ Tess Burleson
||** Signature of Reporting Person
|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,
|** Intentional misstatements or omissions of facts constitute Federal Criminal Violations
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,
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.|
POWER OF ATTORNEY
For Executing Section 16 Forms, Form 144 and Schedule 13D or 13G
Know all by these presents that the undersigned hereby constitutes and
appoints David J. Arthur and Scott Jordan, or any of them signing individually,
the undersigned's true and lawful attorney-in-fact to:
(1) prepare, execute in the undersigned's name and on the undersigned's
behalf, and submit to the Securities and Exchange Commission (the "SEC")
a Form ID, including amendments thereto, and any other documents
necessary or appropriate to obtain codes and passwords enabling the
undersigned to make electronic filings with the SEC of reports required
by Section 16(a) of the Securities and Exchange Act of 1934 or any rule
or regulation of the SEC; and
(2) execute for and on behalf of the undersigned, in the undersigned's
capacity as an officer and/or director of Salarius Pharmaceuticals, Inc.
(the "Company") (a) Forms 3, 4 and 5 (including amendments thereto) in
accordance with Section 16(a) of the Securities Exchange Act of 1934 and
the rules thereunder, (b) Form 144, and (c) Schedule 13D or Schedule
(3) do and perform any and all acts for and on behalf of the undersigned
that may be necessary or desirable to complete and execute any such
Forms 3, 4 and 5, Form 144, and Schedule 13D or Schedule 13G (including
amendments thereto) and timely file such Forms or schedules with the SEC
and any stock exchange, self-regulatory association or any other
(4) take any other action of any type whatsoever in connection with the
foregoing that, in the opinion of such attorney-in-fact, may be of
benefit to, in the best interest of, or legally required of the
undersigned, it being understood that the documents executed by the
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 the attorney-in-fact may approve in the attorney-in-fact's
The undersigned hereby grants to the attorney-in-fact full power and
authority to do and perform all and every act and thing whatsoever requisite,
necessary or 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 the 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
attorney-in-fact, in serving in such capacity at the request of the undersigned,
is not assuming any of the undersigned's responsibilities to comply with Section
16 of the Securities Exchange Act of 1934.
The undersigned agrees that such attorney-in-fact may rely entirely on
information furnished orally or in writing by the undersigned to the attorney-
in-fact. The undersigned also agrees to indemnify and hold harmless such
attorney-in-fact against any losses, claims, damages or liabilities (or actions
in these respects) that arise out of or are based upon any untrue statements or
omissions of necessary facts in the information provided by the undersigned to
such attorney-in fact for purposes of executing, acknowledging, delivering or
filing Form 4 or Form 144 (including amendments thereto) and agrees to reimburse
the attorney-in-fact on demand 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 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
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to
be executed as of the date written below.
Signature: /s/ Tess Burleson
Printed Name: Tess Burleson
Date: March 4, 2019