SEC Form 5 · accession 0001437749-17-002230
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
Dec 31, 2016
Accepted (ET)
Feb 13, 2017 · 4:16 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 | Aug 16, 2016 | P | 80,000 | $0.15 | A | 183,334 | D | |
| Common StockF1,F2 | holding | — | — | — | 49,724,716 | I | Trust |
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 | Feb 29, 2016 | A | — | A | Feb 29, 2016 | Apr 1, 2019 | Common Stock | 1,800,000 | — | D |
Explanation of responses
- F1This transaction was originally reported on Form 4 filed by the Reporting Person on 8-18-16. The Transaction Code was incorrectly reported on the Form 4 and is hereby amended to reflect the correct Transaction Code. This Form 5 also corrects the end of period ownership of the Reporting Person as reported on such Form 4 by also reflecting the Reporting Person's contribution to the Cornelis F. Wit Revocable Living Trust Dated October 15, 2009 as Amended and Restated on June 11, 2015 (the "Trust"), on 1-21-2016, of 49,644,716 shares that had previously been acquired directly by the Reporting Person. The Trust is a revocable trust established by the Reporting Person as grantor with respect to which the Reporting Person is the sole trustee, and the Reporting Person, his spouse and children are beneficiaries, and, as a result, the Reporting Person may be deemed to have retained beneficial ownership of such shares.
- F2The contribution of such shares to the Trust was a change in form of beneficial ownership that was exempt from Section 16 by reason of Rule 16a-13; but should have been reflected in the amount of securities beneficially owned following reported transaction totals reported on the Form 4 filed 8-18-16. The end of the year totals in this Form 5 also reflect the Reporting Person's contribution to the Trust, on September 6, 2016, of the 80,000 shares acquired on 8-18-16. This contribution of shares to the Trust was also a change in form of beneficial ownership that was exempt from Section 16 by reason of Rule 16a-13.
- F3This transaction was originally reported on Form 4 filed by the Reporting Person on 3-2-2016. The Transaction Code was incorrectly reported on the Form 4 and is hereby amended to reflect the correct Transaction Code.