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
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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 DELCATH SYSTEMS, INC. |
810 SEVENTH AVENUE, 35TH FLOOR |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 07/05/2012
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3. Issuer Name and Ticker or Trading Symbol
DELCATH SYSTEMS INC
[ DCTH ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X |
Director |
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10% Owner |
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Officer (give title below) |
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Other (specify below) |
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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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No securities are beneficially owned |
0 |
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 |
Explanation of Responses: |
Remarks: |
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/s/ Barbra Keck, pursuant to a Confirming Statement Executed by Laura A. Brege |
07/09/2012 |
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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. |
Confirming Statement
This Confirming Statement ("Statement") confirms that the undersigned,
Laura Brege, has authorized, directed and designated each of
Barbra Keck, Peter Graham, and Graham Miao (each a "Designee" and
together, the "Designees"), or either of them acting singly, to:
(1) prepare, execute and file for and on behalf of the undersigned
with the U.S. Securities and Exchange Commission (the "SEC") a Form ID,
including amendments thereto, enabling the undersigned to make electronic
filings with the SEC of reports required by Section 16(a) of the
Securities Exchange Act of 1934 and any rule or regulation thereunder;
and (2) prepare, execute and file for and on behalf of the
undersigned with the SEC and any stock exchange or similar authority,
all Forms 3, 4, and 5, including any amendments thereto, that the
undersigned is required to file as an officer and/or director of
Delcath Systems, Inc. (the "Company") in accordance with Section 16(a)
of the Securities Exchange Act of 1934 and any rule or regulation
thereunder.
The authority of the Designees under this Statement shall continue
until the undersigned is no longer required to file Forms 3, 4,
and 5 with respect to the undersigned's holdings of and/or transactions
in securities of the Company, unless earlier revoked by the undersigned
in a signed writing delivered to the Designees. The undersigned
acknowledges that the Designees are not assuming, nor is the Company
assuming, any of the undersigned's responsibilities to comply with
Section 16 of the Securities Exchange Act of 1934. This Statement
is not intended to be a power of attorney as defined in the New York
General Obligations Law, Article 5, Title 15, Section 5-1501, and
in the event this Statement is determined to be a power of attorney
under such statute, this Statement shall not revoke any power of
attorney previously executed by the undersigned and shall not be
revoked by any subsequent power of attorney unless such subsequent
power of attorney expressly provides that it revokes this Statement
by referring to the date and subject hereof.
Date: July 5, 2012
Undersigned's Name: Laura Brege
Undersigned's Signature: /s/ Laura Brege