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*
| 525 UNIVERSITY AVENUE |
| SUITE 800 |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
06/22/2021
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3. Issuer Name and Ticker or Trading Symbol
Talkspace, Inc.
[ TALK ]
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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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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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| No securities are beneficially owned. |
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/s/ Matthew De Dominicis, Attorney-in-Fact for Jeffrey Crowe |
06/24/2021 |
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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. |
LIMITEDPOWER OF ATTORNEY
FOR
SECTION 16 AND SECTION REPORTING OBLIGATIONS
Know all by these present, that the undersigned hereby constitutes and appoints
Matthew De Dominicis, the undersigned's true and lawful attorneys-in-fact, with
full power and authority as hereinafter described on behalf of and in the name,
place and stead of the undersigned t to:
(1) prepare, execute, acknowledge and deliver, for and on behalf of the
undersigned, all reports and filings required by (a) Section 16(a) of the
Securities Exchange Act of 1934 and the rules promulgated thereunder (the
"Section 16 Reports") and (b) Section 13 of the Securities and Exchange Act of
1934 and the rules promulgated thereunder (the "Section 13 Reports").
(2) do and perform any and all acts for and on behalf of the undersigned which
may be necessary or desirable to file any such Section 16 Reports and Section 13
Reports, or any amendments thereto, with the United States Securities and
Exchange Commission and any other authority; and
(3) take any other action of any type whatsoever in connection with the
foregoing which, 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 such attorney in fact on behalf of the
undersigned pursuant to this Limited Power of Attorney shall be in such form and
shall contain such terms and conditions as such attorney in fact may approve in
such attorney in fact's discretion.
The undersigned hereby grants to each such attorney-in-fact full power and
authority to do and perform each 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 and acting, with full power of substitution or
revocation, hereby ratifying and confirming all that such attorney-in-fact, or
his substitute or substitutes, shall lawfully do or cause to be done by virtue
of this Limited Power of Attorney and the rights and powers herein granted. The
undersigned acknowledges that the foregoing attorneys-in-fact, in serving in
such capacity at the request of the undersigned, are not assuming any of the
undersigned's responsibilities to comply with Section 16 and Section 13 of the
Securities Exchange Act of 1934, as amended.
This Limited Power of Attorney shall not revoke any previous Limited Power of
Attorney granted by the undersigned with respect to the subject matter hereof,
and shall remain in full force and effect until the undersigned is no longer
required to file Section 16 Reports and Section 13 Reports, unless earlier
revoked by the undersigned in a subsequently executed Limited Power of Attorney
or a signed writing delivered to the foregoing attorneys-in-fact.
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be
executed as of this 20th day of June, 2017.
/s/ Jeffrey M. Crowe
Signature
Jeffrey M. Crowe
Print Name
