SEC Form 4 · accession 0001454170-16-000007
GOLDEN QUEEN MINING CO LTD · GQM
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Thomas Moragne Clay
Director · 10% Owner
Period of report
Nov 21, 2016
Accepted (ET)
Nov 23, 2016 · 10:41 am 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 Stock | holding | — | — | — | 1,806,400 | D | ||
| Common StockF1 | holding | — | — | — | 17,047,739 | I | By grantor retained annuity trust | |
| Common StockF2 | holding | — | — | — | 1,344,269 | I | By trust | |
| Common StockF3 | holding | — | — | — | 807,250 | I | By trust |
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| WarrantF5,F4 | $0.85 | Nov 21, 2016 | J | 4,773,600 | A | Nov 21, 2016 | Nov 21, 2021 | Common Shares | 4,773,600 | 4,773,600 | I |
| WarrantF5,F6 | $0.85 | Nov 21, 2016 | J | 1,226,400 | A | Nov 21, 2016 | Nov 21, 2021 | Common Shares | 1,226,400 | 1,226,400 | I |
Explanation of responses
- F1Represents shares owned by 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's father is the donor of the assets to the 2016-2 GRAT, and 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 and is the donor of the assets to Monadnock. The reporting person disclaims beneficial ownership 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 (the "CF 2009 Trust"), which owns 50% of Arctic Coast. The reporting person's father is the donor of the portion of Arctic Coast held by the CF 2009 Trust. The reporting person is a director of Arctic Coast.
- F4On November 21, 2016, the issuer issued a warrant to purchase 4,773,600 shares of common stock to the Landon T. Clay 2009 Irrevocable Trust dated March 6, 2009 (the "LTC 2009 Trust"), of which the reporting person is a trustee. The warrant is currently exercisable and expires on November 21, 2021.
- F5The warrant was issued in connection with the Second Amended and Restated Term Loan Agreement (the "Loan Agreement"), dated November 21, 2016, by and among the issuer, the LTC 2009 Trust, the CF 2009 Trust and EHT, LLC. The Loan Agreement is described in the issuer's Current Report on Form 8-K filed with the Securities and Exchange Commission on November 21, 2016.
- F6On November 21, 2016, the issuer issued a warrant to purchase 1,226,400 shares of common stock to the CF 2009 Trust, of which the reporting person is a trustee. The warrant is currently exercisable and expires on November 21, 2021.