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 |
| 1633 BROADWAY, SUITE 22C |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
07/24/2019
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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 |
|
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)
|
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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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: |
|
| No securities are beneficially owned. |
|
/s/ John R. Sylvester |
07/29/2019 |
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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. |
Exhibit 24
Confirming Statement
This Confirming Statement ("Statement") confirms that the undersigned, John R.
Sylvester, has authorized, directed and designated each of Jennifer Simpson and
Barbra Keck (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 24, 2019
Undersigned's Name: John R. Sylvester
Undersigned's Signature: /s/ John R. Sylvester
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