SEC Form 4 · accession 0001437749-15-021273
OMNICOMM SYSTEMS INC · OMCM
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Cornelis F Wit
Officer — Chief Executive Officer · Director · 10% Owner
Period of report
Nov 19, 2015
Accepted (ET)
Nov 20, 2015 · 2:30 pm EST
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0001034592
Table I — non-derivative securities
| Security | Date | Code | Shares | Price | A/D | Owned after | D/I | Nature of ownership |
|---|---|---|---|---|---|---|---|---|
| Common StockF1,F2 | Nov 19, 2015 | A | 37,023,517 | $0.25 | A | 49,828,050 | D |
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Common Stock Warrant | $0.25 | Nov 19, 2015 | J | 11,440,000 | D | Jan 31, 2015 | Nov 19, 2015 | Common Stock | 11,440,000 | 0 | D |
| Common Stock Warrant | $0.25 | Nov 19, 2015 | J | 400,000 | D | Jan 31, 2015 | Nov 19, 2015 | Common Stock | 400,000 | 6,000,000 | D |
| Convertible Debt | $0.25 | Nov 19, 2015 | M | 475,000 | D | Sep 30, 2009 | Nov 19, 2015 | Common Stock | 1,900,000 | 2,500,000 | D |
| Common Stock Warrant | $0.25 | Nov 19, 2015 | J | 2,116,000 | D | Jan 31, 2015 | Nov 19, 2015 | Common Stock | 2,116,000 | 0 | D |
| Common Stock Warrant | $0.25 | Nov 19, 2015 | J | 3,920,000 | D | Jan 31, 2015 | Nov 19, 2015 | Common Stock | 3,920,000 | 0 | D |
| Common Stock Warrant | $0.25 | Nov 19, 2015 | J | 3,800,000 | D | Jan 31, 2015 | Nov 19, 2015 | Common Stock | 3,800,000 | 0 | D |
| Common Stock Warrant | $0.25 | Nov 19, 2015 | J | 27,517 | D | Mar 31, 2011 | Nov 19, 2015 | Common Stock | 27,517 | 0 | D |
| Common Stock Warrant | $0.25 | Nov 19, 2015 | J | 1,900,000 | D | Sep 30, 2009 | Nov 19, 2015 | Common Stock | 1,900,000 | 2,500,000 | D |
| Common Stock Warrant | $0.25 | Nov 19, 2015 | J | 5,760,000 | D | Dec 31, 2009 | Nov 19, 2015 | Common Stock | 5,760,000 | 0 | D |
| Convertible Debt | $0.25 | Nov 19, 2015 | M | 1,440,000 | D | Dec 31, 2009 | Nov 19, 2015 | Common Stock | 5,760,000 | 0 | D |
Explanation of responses
- F1On November 19, 2015, OmniComm Systems, Inc. (the "Company") issued 29,363,517 shares of common stock to Mr. Wit in exchange for the (1) satisfaction in full of an aggregate principal amount of $7,339,000 promissory notes and a convertible debenture, and (2) cancellation and termination of warrants exercisable into an aggregate amount of 29,363,517 shares of the Company's common stock at an exercise price of $.25 per share.
- F2On November 19, 2015, the Company issued 7,660,000 shares of common stock to Cornelis F. Wit, the Chief Executive Officer and Director of the Company ("Mr. Wit"), upon conversion of an aggregate principal amount of $1,915,000 convertible debentures at a conversion price of $.25 per share.