4: Statement of changes in beneficial ownership of securities
Published on May 17, 2017
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT OF CHANGES IN 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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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | |||
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 control number. | SEC 1474 (9-02) |
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 3) |
2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) |
5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4, and 5) |
6. Date Exercisable and Expiration Date (Month/Day/Year) |
7. Title and Amount of Underlying Securities (Instr. 3 and 4) |
8. Price of Derivative Security (Instr. 5) |
9. Number of Derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) |
10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
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Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||||||
Convertible Note | $ 0.05 | 05/15/2017 | 05/15/2017 | A | $ 11,000 (1) | 05/15/2017 | (2) | Common Stock | 220,000 | $ 10,000 | 470,000 | D | |||
Warrants | $ 0.05 | 05/15/2017 | 05/15/2017 | A | 110,000 | 05/15/2017 | 05/15/2018 | Common Stock | 110,000 | (3) | 580,000 | D | |||
Convertible Note | $ 0.05 | 05/15/2017 | 05/15/2017 | D | $ 11,000 | (2) | (2) | Common Stock | 220,000 | $ 11,000 (4) | 360,000 | D |
Reporting Owners
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Munn Richard William 23902 FM 2978 TOMBALL, TX 77375 |
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Signatures
/s/ Richard W. Munn | 05/17/2017 | |
**Signature of Reporting Person | Date |
Explanation of Responses:
* | 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). |
(1) | Reporting Person acquired Issuer's Convertible Note in the principal amount of $11,000, for a purchase price of $10,000, convertible into 220,000 shares of common stock of Issuer. |
(2) | Not Applicable. |
(3) | Reporting Person acquired Issuer's Warrants as part of Reporting Person's purchase of Issuer's Convertible Note reported above. |
(4) | Reporting Person converted the Convertible Note listed above and described in Footnote 1 of this Form 4. |