SEC Form 5 · accession 0001179110-16-019353
CHASE PACKAGING CORP · WHLT
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Herbert M Gardner
Officer — Vice President · Director · 10% Owner
Period of report
Dec 31, 2015
Accepted (ET)
Feb 16, 2016 · 7:31 pm EST
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0001025771
Table I — non-derivative securities
| Security | Date | Code | Shares | Price | A/D | Owned after | D/I | Nature of ownership |
|---|---|---|---|---|---|---|---|---|
| Common Stock | holding | — | — | — | 927,297 | D | ||
| Common StockF1 | holding | — | — | — | 167,590 | I | By GST U/W/O Mary Gardner |
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Series A 10% Convertible Preferred StockF4,F5,F2,F3 | $0.10 | holding | — | — | — | — | — | Common Stock | 2,167,000 | 2,167,000 | D |
| Series A 10% Convertible Preferred StockF4,F1,F2,F3 | $0.10 | holding | — | — | — | — | — | Common Stock | 384,000 | 384,000 | I |
| WarrantsF6,F2 | $0.15 | holding | — | — | — | — | Sep 7, 2017 | Common Stock | 623,500 | 623,500 | D |
| WarrantsF1,F2 | $0.15 | holding | — | — | — | — | Sep 7, 2017 | Common Stock | 89,000 | 89,000 | I |
| Incentive Stock OptionF2 | $0.03 | holding | — | — | — | — | Jun 24, 2018 | CommonStock | 50,000 | 50,000 | D |
Explanation of responses
- F1Reporting person disclaims beneficial ownership of shares and warrants owned by the Generation Skipping Marital Trust U/W/O Mary K. Gardner, of which the reporting person is a Co-Trustee.
- F2Currently exercisable.
- F3Not applicable.
- F4Adjusted to reflect the annual 10% stock dividends paid by the Company to all holders of Series A Convertible Preferred Stock on December 1, 2015.
- F51,164 shares of Series A Convertible Preferred Stock (convertible into 1,164,000 Common shares) are held in a Roth IRA for reporting person.
- F6266,500 Warrants are held in reporting persons IRA rollover.