SEC Form 3

FORM 3

UNITED STATES SECURITIES AND EXCHANGE

COMMISSION

OMB APPROVAL

Washington, D.C. 20549

OMB Number:

3235-

INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF

0104

Estimated average burden

0.5

SECURITIES

response:

hours per

Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934

or Section 30(h) of the Investment Company Act of 1940

1. Name and Address of Reporting Person*

2. Date of Event

3. Issuer Name and Ticker or Trading Symbol

Wenderow Tal Baruch

(Month/Day/Year)

Microbot Medical Inc.[ MBOT ]

Requiring Statement

08/01/2020

(Last)

(First)

(Middle)

4. Relationship of Reporting Person(s) to

5. If Amendment, Date of Original

C/O MICROBOT MEDICAL INC.

Issuer

Filed (Month/Day/Year)

(Check all applicable)

25 RECREATION PARK DRIVE,

X

Director

10% Owner

6. Individual or Joint/Group Filing

Officer (give

Other (specify

UNIT 108

(Check Applicable Line)

title below)

below)

X

Form filed by One Reporting

(Street)

Person

02043

Form filed by More than One

HINGHAM MA

Reporting Person

(City)

(State)

(Zip)

Table I - Non-Derivative Securities Beneficially Owned

1. Title of Security (Instr. 4)

2. Amount of Securities

3. Ownership

4. Nature of Indirect Beneficial

Beneficially Owned (Instr.

Form: Direct

Ownership (Instr. 5)

4)

(D) or Indirect

(I) (Instr. 5)

Table II - Derivative Securities Beneficially Owned

(e.g., puts, calls, warrants, options, convertible securities)

1. Title of Derivative Security (Instr. 4)

2. Date Exercisable and

3. Title and Amount of Securities

4.

5.

6. Nature of

Expiration Date

Underlying Derivative Security

Conversion

Ownership

Indirect Beneficial

(Month/Day/Year)

(Instr. 4)

or Exercise

Form:

Ownership (Instr.

Price of

Direct (D)

5)

Amount

Derivative

or Indirect

or

Security

(I) (Instr. 5)

Date

Expiration

Number

Title

of

Exercisable

Date

Shares

Explanation of Responses:

No securities are beneficially owned.

/s/ Tal Wenderow

09/08/2020

** Signature of Reporting

Date

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, 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.

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Microbot Medical Inc. published this content on 09 September 2020 and is solely responsible for the information contained therein. Distributed by Public, unedited and unaltered, on 10 September 2020 07:54:03 UTC