# EDGAR Filing Document

**Accession Number:** 0001793712
**File Stem:** 0001104659-23-021716
**Filing Date:** 2023-2
**Character Count:** 9961
**Document Hash:** bc612c88be0a656b0483d28fc2c8849c
**Contains OCR:** False
**Source Format:** 

## Filing Content

## Filing Summary
**0001104659-23-021716.hdr.sgml**: 20230214

**ACCESSION NUMBER**: 0001104659-23-021716

**CONFORMED SUBMISSION TYPE**: 5

**PUBLIC DOCUMENT COUNT**: 1

**CONFORMED PERIOD OF REPORT**: 20221231

**FILED AS OF DATE**: 20230214

**DATE AS OF CHANGE**: 20230214

**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** Chang William H
- **CENTRAL INDEX KEY:** 0001594408

**FILING VALUES:**
- **FORM TYPE:** 5
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-36305
- **FILM NUMBER:** 23630266

**MAIL ADDRESS:**
- **STREET 1:** C/O SEMLER SCIENTIFIC, INC.
- **STREET 2:** 911 BERN COURT, SUITE 110
- **CITY:** SAN JOSE
- **STATE:** CA
- **ZIP:** 95112
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** Chang Diana Shon
- **CENTRAL INDEX KEY:** 0001793712

**FILING VALUES:**
- **FORM TYPE:** 5
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-36305
- **FILM NUMBER:** 23630265

**MAIL ADDRESS:**
- **STREET 1:** 1301 SHOREWAY RD., SUITE 150
- **CITY:** BELMONT
- **STATE:** CA
- **ZIP:** 94002
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** William H.C. Chang & Diana Shon Chang TTEE Chang Family Trust U/A DTD 10/23/2006
- **CENTRAL INDEX KEY:** 0001742975
- **STATE OF INCORPORATION:** CA
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 5
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-36305
- **FILM NUMBER:** 23630267

**BUSINESS ADDRESS:**
- **STREET 1:** C/O SEMLER SCIENTIFIC, INC.
- **STREET 2:** 911 BERN CT.
- **CITY:** SAN JOSE
- **STATE:** CA
- **ZIP:** 95112
- **BUSINESS PHONE:** (877) 774-4211

**MAIL ADDRESS:**
- **STREET 1:** C/O SEMLER SCIENTIFIC, INC.
- **STREET 2:** 911 BERN CT.
- **CITY:** SAN JOSE
- **STATE:** CA
- **ZIP:** 95112
**ISSUER**: 

**COMPANY DATA:**
- **COMPANY CONFORMED NAME:** Semler Scientific, Inc.
- **CENTRAL INDEX KEY:** 0001554859
- **STANDARD INDUSTRIAL CLASSIFICATION:** ELECTROMEDICAL & ELECTROTHERAPEUTIC APPARATUS [3845]
- **IRS NUMBER:** 261367393
- **STATE OF INCORPORATION:** DE
- **FISCAL YEAR END:** 1231

**BUSINESS ADDRESS:**
- **STREET 1:** 2340-2348 WALSH AVENUE, SUITE 2344
- **CITY:** SANTA CLARA
- **STATE:** CA
- **ZIP:** 95051
- **BUSINESS PHONE:** 408-627-4557

**MAIL ADDRESS:**
- **STREET 1:** 2340-2348 WALSH AVENUE, SUITE 2344
- **CITY:** SANTA CLARA
- **STATE:** CA
- **ZIP:** 95051

### UNITED STATES SECURITIES AND EXCHANGE COMMISSION
**Washington, D.C. 20549**

## FORM 5

### STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

[ ] Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).

[ ] Check this box to indicate that a transaction was made pursuant to a contract, instruction or written plan for the purchase or sale of equity securities of the issuer that is intended to satisfy the affirmative defense conditions of Rule 10b5-1(c). See Instruction 10.

---

| | | |
|:---|:---|:---|
| **1. Name and Address of Reporting Person**<sup>*</sup><br>William H.C. Chang & Diana Shon Chang TTEE Chang Family Trust U/A DTD 10/23/2006<br><sub>(Last) (First) (Middle)</sub><br>C/O SEMLER SCIENTIFIC, INC.<br>2340-2348 WALSH AVENUE, SUITE 2344<br><sub>(Street)</sub><br>SANTA CLARA, CA 95051<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2022-12-31 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[ ] Director [X] 10% Owner<br>[ ] Officer (give title below) [ ] Other (specify below)<br>_ _ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>Semler Scientific, Inc. [ SMLR ] | **4. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  | **6. Individual or Joint/Group Filing (Check Applicable Line)**<br>[ ] Form filed by One Reporting Person<br>[X] Form filed by More than One Reporting Person |

---

---

| | | |
|:---|:---|:---|
| **1. Name and Address of Reporting Person**<sup>*</sup><br>Chang William H<br><sub>(Last) (First) (Middle)</sub><br>C/O SEMLER SCIENTIFIC, INC.<br>2340-2348 WALSH AVENUE, SUITE 2344<br><sub>(Street)</sub><br>SANTA CLARA, CA 95051<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2022-12-31 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[ ] Director [X] 10% Owner<br>[ ] Officer (give title below) [ ] Other (specify below)<br>_ _ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>Semler Scientific, Inc. [ SMLR ] | **4. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  | **6. Individual or Joint/Group Filing (Check Applicable Line)**<br>[ ] Form filed by One Reporting Person<br>[X] Form filed by More than One Reporting Person |

---

---

| | | |
|:---|:---|:---|
| **1. Name and Address of Reporting Person**<sup>*</sup><br>Chang Diana Shon<br><sub>(Last) (First) (Middle)</sub><br>C/O SEMLER SCIENTIFIC, INC.<br>2340-2348 WALSH AVENUE, SUITE 2344<br><sub>(Street)</sub><br>SANTA CLARA, CA 95051<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2022-12-31 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[ ] Director [X] 10% Owner<br>[ ] Officer (give title below) [ ] Other (specify below)<br>_ _ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>Semler Scientific, Inc. [ SMLR ] | **4. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  | **6. Individual or Joint/Group Filing (Check Applicable Line)**<br>[ ] Form filed by One Reporting Person<br>[X] Form filed by More than One Reporting Person |

---

## Table I - Non-Derivative Securities

---

|  |  |  |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| 1. Title of Security | 2. Transaction Date | 2A. Deemed Execution Date | 3. Transaction Code (V) | 3. Transaction Code (V) | 4. Securities Acquired (A) or Disposed of (D) | 4. Securities Acquired (A) or Disposed of (D) | 4. Securities Acquired (A) or Disposed of (D) | 5. Amount of Securities Beneficially Owned | 6. Ownership Form | 7. Nature of Indirect Beneficial Ownership |
| 1. Title of Security | 2. Transaction Date | 2A. Deemed Execution Date | Code | V | Amount | (A) or (D) | Price | 5. Amount of Securities Beneficially Owned | 6. Ownership Form | 7. Nature of Indirect Beneficial Ownership |
| Common Stock | 2022-09-30 |  | G |  | 189522 | D | $0 | 105582 | D<sup>(1)</sup> |  |
| Common Stock | 2022-09-30 |  | G |  | 189522 | D | $0 | 105582 | D<sup>(2)</sup> |  |
| Common Stock | 2022-09-30 |  | G |  | 238248 | A | $0 | 522237 | D<sup>(3)</sup> |  |
| Common Stock | 2022-11-02 |  | G |  | 150000 | A | $0 | 255582 | D<sup>(1)</sup> |  |
| Common Stock | 2022-11-02 |  | G |  | 150000 | A | $0 | 255582 | D<sup>(2)</sup> |  |
| Common Stock | 2022-11-02 |  | G |  | 300000 | D | $0 | 222237 | D<sup>(3)</sup> |  |
| Common Stock | 2022-11-04 |  | G |  | 105582 | D | $0 | 150000 | D<sup>(4)</sup> |  |
| Common Stock | 2022-11-04 |  | G |  | 105582 | D | $0 | 150000 | D<sup>(5)</sup> |  |
| Common Stock | 2022-11-04 |  | G |  | 119754 | A | $0 | 341991 | D<sup>(3)</sup> |  |
| Common Stock |  |  |  |  |  |  |  | 241508 | I<sup>(6)</sup> | Through LP |

---

## Table II - Derivative Securities

---

|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| 1. Title of Derivative Security | 2. Conversion or Exercise Price | 3. Transaction Date | 3A. Deemed Execution Date | 4. Transaction Code (V) | 4. Transaction Code (V) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) | 6. Date Exercisable and Expiration Date | 6. Date Exercisable and Expiration Date | 7. Title and Amount of Underlying Securities | 7. Title and Amount of Underlying Securities | 8. Price of Derivative Security | 9. Number of Derivative Securities Beneficially Owned | 10. Ownership Form | 11. Nature of Indirect Beneficial Ownership |
| 1. Title of Derivative Security | 2. Conversion or Exercise Price | 3. Transaction Date | 3A. Deemed Execution Date | Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | 8. Price of Derivative Security | 9. Number of Derivative Securities Beneficially Owned | 10. Ownership Form | 11. Nature of Indirect Beneficial Ownership |
|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |

---

### Footnotes:

(1) Shares held in six GRATs, for which Mr. Chang acts as sole Trustee and has voting and investment control.

(2) Shares held in six GRATs, for which Mrs. Chang acts as sole Trustee and has voting and investment control.

(3) Shares are held directly by William H.C. Chang & Diana Shon Chang TTEE Chang Family Trust U/A DTD 10/23/2006.

(4) Shares are held in three GRATs, for which Mr. Chang acts as sole Trustee and has voting and investment control.

(5) Shares are held in three GRATs, for which Mrs. Chang acts as sole Trustee and has voting and investment control.

(6) Shares are held in Chang 2020 Delaware LP.

**Signature:** /s/ William H.C. Chang, Co-Trustee  
**Date:** 2023-02-14

**Signature:** /s/ William H.C. Chang  
**Date:** 2023-02-14

**Signature:** /s/ Diana Shon Chang  
**Date:** 2023-02-14

### Remarks:

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 4 (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.**