SEC Form 4 · accession 0001454170-16-000006
GOLDEN QUEEN MINING CO LTD · GQM
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Thomas Moragne Clay
Officer — CEO · Director
Period of report
Jan 14, 2016
Accepted (ET)
Jan 19, 2016 · 2:18 pm EST
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0001025362
Table I — non-derivative securities
| Security | Date | Code | Shares | Price | A/D | Owned after | D/I | Nature of ownership |
|---|---|---|---|---|---|---|---|---|
| Common StockF1 | Jan 14, 2016 | G | 17,047,739 | $0.00 | A | 17,047,739 | I | By grantor retained annuity trust |
| Common Stock | holding | — | — | — | 1,806,400 | D | ||
| Common StockF2 | holding | — | — | — | 1,344,269 | I | By trust | |
| Common StockF3 | holding | — | — | — | 807,250 | I | By trust |
Table II — derivative securities
No Table II lines on this filing.
Explanation of responses
- F1On January 14, 2016, the reporting person's father, Landon T. Clay transferred an aggregate of 17,047,739 shares of common stock of the issuer into the Landon T. Clay 2016-2 Annuity Trust u/a dated January 14, 2016(the "2016-2 GRAT")for the benefit of the reporting person's father. The reporting person is the sole trustee under the 2016-2 GRAT. The reporting person disclaims beneficial ownership of the shares held by the 2016-2 GRAT.
- F2Represents shares owned by the Monadnock Charitable Lead Annuity Trust dated May 31, 1996 ("Monadnock"). The reporting person has a remainder beneficial interest in the assets held by Monadnock. The reporting person's father provides investment advisory services to Monadnock. The reporting person disclaims beneficial interest of the shares held by Monadnock except to the extent of his proportionate pecuniary interest therein.
- F3Represents shares owned by Arctic Coast Petroleums, Ltd. ("Arctic Coast"). The reporting person is a trustee of the Clay Family 2009 Irrevocable Trust dated April 14, 2009 which owns 50% of Arctic Coast. The reporting person is a director of Arctic Coast.