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, SUITE 3505 |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
05/02/2011
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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)
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Director |
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10% Owner |
| X |
Officer (give title below) |
|
Other (specify below) |
| Exec. V. P., Global Operations |
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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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| No securites are beneficially owned. |
0 |
D |
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Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
|
|---|
| 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: |
|
|
/s/ David McDonald, pursuant to a Confirming Statement executed by Harold C. Mapes |
05/04/2011 |
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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, Harold C. Mapes, has authorized, directed and
designated each of Barbra Keck, David McDonald and Peter
Graham (each a "Designee" and together, the "Designees"), or
any 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: April 28, 2011
Undersigned's Name: Harold C. Mapes
Undersigned's Signature: /s/ Harold C. Mapes
1838449.2
..2
1838449.2
