UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | SEC 1473 (7-02) | ||
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 control number. |
1. Title of Derivative Security (Instr. 4) |
2. Date Exercisable and Expiration Date (Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) |
4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 5) |
6. Nature of Indirect Beneficial Ownership (Instr. 5) |
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Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Series B Convertible Preferred Stock, $0.01 par value | Â (2) | Â (2) | Common Stock, $0.001 par value | 2,200,000 | $ (2) | I | See footnote (1) |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Nakata Kousuke C/O MEDICINOVA, INC. 4275 EXECUTIVE SQUARE, SUITE 650 LA JOLLA, CA 92037 |
 X |  |  |  |
/s/ Kousuke Nakata | 01/14/2014 | |
**Signature of Reporting Person | Date |
* | 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). |
(1) | Held by Kissei Pharmaceutical Co., Ltd. ("Kissei"), of which Mr. Nakata serves as Director, Licensing and Clinical Development. Mr. Nakata disclaims beneficial ownership of such shares except to the extent of his pecuniary interest therein. Kissei held such shares on November 29, 2011, the date on which Mr. Nakata became a director of MediciNova, Inc. |
(2) | Kissei holds 220,000 shares of Series B Convertible Preferred Stock. The Series B Convertible Preferred Stock is convertible at any time, at the holder's election, into Common Stock initially at a rate of 10 shares of Common Stock for each share of Series B Convertible Preferred Stock, and has no expiration. |
 Remarks: Exhibit List: Exhibit 24 - Power of Attorney |