SEC Form 4 · accession 0001454170-17-000003
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
Nov 21, 2017
Accepted (ET)
Nov 22, 2017 · 9:42 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 StockF1 | Nov 21, 2017 | J | 26,114 | $0.00 | A | 26,114 | I | By corporation |
| Common StockF2 | holding | — | — | — | 10,163,295 | I | By grantor retained annuity trust | |
| Common StockF3 | holding | — | — | — | 1,344,269 | I | By trust | |
| Common Stock | holding | — | — | — | 1,806,400 | D | ||
| Common StockF4 | holding | — | — | — | 807,250 | I | By trust |
Table II — derivative securities
No Table II lines on this filing.
Explanation of responses
- F1Represents shares owned by LTC Corporation ("LTC Corp"). The reporting person was appointed President of LTC Corp on November 21, 2017. LTC Corp is wholly owned by the estate of the reporting person's late father. The reporting person disclaims beneficial ownership of the shares held by LTC Corp.
- F2Represents 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 estate of the reporting person's father. The reporting person's father was 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.
- F3Represents shares owned by the Monadnock Charitable Lead Annuity Trust dated May 31, 1996 ("Monadnock"). The reporting person's father was the donor of the assets to Monadnock and the reporting person has a remainder beneficial interest in the assets held by Monadnock. The reporting person disclaims beneficial ownership of the shares held by Monadnock except to the extent of his proportionate pecuniary interest therein.
- F4Represents 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 was the donor of the portion of Arctic Coast held by the CF 2009 Trust. The reporting person is a director of Arctic Coast.