SEC Form 4 · accession 0001144204-16-076152
INTELLINETICS, INC. · INLX
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Murray H Gross
Director
Period of report
Dec 31, 2015
Accepted (ET)
Jan 19, 2016 · 8:04 pm EST
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0001081745
Table I — non-derivative securities
| Security | Date | Code | Shares | Price | A/D | Owned after | D/I | Nature of ownership |
|---|---|---|---|---|---|---|---|---|
| COMMON STOCK | Dec 31, 2015 | C | 113,993 | $0.56 | A | 296,432 | D | |
| COMMON STOCKF1 | Jan 2, 2016 | A | 36,111 | $0.90 | A | 332,543 | D |
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Convertible NoteF2,F3 | $0.56 | Dec 31, 2015 | C | 68,803 | D | May 30, 2014 | — | Common stock | 113,933 | 640,000 | D |
| WarrantF2 | $0.65 | Dec 31, 2015 | C | 53,169 | A | Dec 30, 2015 | Dec 30, 2020 | Common stock | 53,169 | 693,169 | D |
Explanation of responses
- F1Grant of stock under the 2015 Intellinetics, Inc. Equity Incentive Plan for director services rendered.
- F2Convertible Note was converted into both common stock and warrants pursuant to a private offering conducted by the Company. Notes were converted to common stock attheir stated conversion price, and warrants were granted in an amount equal to 50% of the total principal and interest converted, multiplied by 0.6.
- F3N/A.