SEC 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
|Estimated average burden|
|hours per response:
1. Name and Address of Reporting Person*
|C/O WAITR HOLDINGS INC.|
|844 RYAN STREET, SUITE 300|
2. Date of Event Requiring Statement
3. Issuer Name and Ticker or Trading Symbol
Waitr Holdings Inc.
[ WTRH ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
||Officer (give title below)
||Other (specify below)
5. If Amendment, Date of Original Filed
6. Individual or Joint/Group Filing (Check Applicable Line)
||Form filed by One Reporting Person
||Form filed by More than One Reporting Person
|Table I - Non-Derivative Securities Beneficially Owned|
|1. Title of Security (Instr.
Amount of Securities Beneficially Owned (Instr.
||3. Ownership Form: Direct (D) or Indirect (I) (Instr.
||4. Nature of Indirect Beneficial Ownership (Instr.
Table II - Derivative Securities Beneficially Owned|
(e.g., puts, calls, warrants, options, convertible securities)
|1. Title of Derivative Security (Instr.
||2. Date Exercisable and Expiration Date
||3. Title and Amount of Securities Underlying Derivative Security (Instr.
||4. Conversion or Exercise Price of Derivative Security
||5. Ownership Form: Direct (D) or Indirect (I) (Instr.
||6. Nature of Indirect Beneficial Ownership (Instr.
||Amount or Number of Shares
|Explanation of Responses:|
|No securities are beneficially owned.|
||/s/ Joel L. Rubinstein, Attorney-in-Fact
||** Signature of Reporting 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,
|** Intentional misstatements or omissions of facts constitute Federal Criminal Violations
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,
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.|
POWER OF ATTORNEY
The undersigned constitutes and appoints Joel Rubinstein, Elliott Smith,
Jerilyn Laskie, and Tyler Quintero, or any of them acting singly, as the
undersigned's true and lawful attorneys- in-fact and agents, with full power of
substitution and resubstitution, for the undersigned and in the undersigned's
name, place and stead, to:
1. prepare, sign, and submit to the U.S. Securities and Exchange
Commission (the "SEC") on its Electronic Data Gathering, Analysis, and Retrieval
("EDGAR") Filer Management website a Form ID application, including any
amendments and exhibits thereto, and any other related documents as may be
necessary or appropriate, to obtain from the SEC access codes to permit filing
on the SEC's EDGAR system, granting unto said attorneys-in-fact and agents, and
each of them, full power and authority to do and perform each act and thing
requisite and necessary to be done as required by any rule or regulation of the
SEC and the EDGAR Filer Manual as fully and to all intents and purposes as the
undersigned might or could do in person, hereby ratifying and confirming all
that said attorneys-in-fact and agents, and each of them, may lawfully do or
cause to be done by virtue hereof; and
2. sign any and all SEC
statements of beneficial ownership of securities
of Waitr Holdings Inc. (the "Company") on Schedule 13D as required under Section
13 and Forms 3, 4 and 5 as required under Section 16(a) of the Securities
Exchange Act of 1934, as amended, and any amendments thereto, and to file the
same with all exhibits thereto, and other documents in connection therewith,
with the SEC, the Company and any stock exchange on which any of the Company's
securities are listed, granting unto said attorneys-in-fact and agents, and each
of them, full power and authority to do and perform each act and thing requisite
and necessary to be done under said Section 13 and Section 16(a), as fully and
to all intents and purposes as the undersigned might or could do in person,
hereby ratifying and confirming all that said attorneys- in-fact and agents, and
each of them, may lawfully do or cause to be done by virtue hereof.
A copy of this power of attorney shall be filed with the SEC. The
authorization set forth above shall continue in full force and effect until the
undersigned revokes such authorization by written instructions to the attorneys-
The authority granted hereby shall in no event be deemed to impose or
create any duty on behalf of the attorneys-in-fact with respect to the
undersigned's obligations to file a Form ID, Schedule 13Ds and Forms 3, 4 and 5
with the SEC.
Dated: January 9, 2019
/s/ Kian Salehi-Moshaei