SEC Form 4 · accession 0001144204-16-089038

INTELLINETICS, INC. · INLX

Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗

Reporting owner

10% Owner

Period of report

Dec 29, 2015

Accepted (ET)

Mar 21, 2016 · 6:13 am EDT

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^F1,F2	Dec 29, 2015	P$0	50,000	—	A	290,936	I	See FN
COMMON STOCK^F1,F3	Dec 29, 2015	P$0	50,000	—	A	340,936	I	See FN
COMMON STOCK^F1,F4	Dec 29, 2015	P$0	50,000	—	A	390,936	I	See FN
COMMON STOCK^F1,F5	Dec 29, 2015	P$0	50,000	—	A	440,936	I	See FN
COMMON STOCK	Dec 31, 2015	C	2,340,230	$1,019,985.00	A	2,781,166	D
COMMON STOCK^F1	Jan 25, 2015	P$0	25,198	—	A	2,806,364	D

Security	Conv. / exercise price	Date	Code	Shares	A/D	Exercisable	Expires	Underlying	Underlying shares	Owned after	D/I
Warrant^F1,F2	$0.65	Dec 29, 2015	P	25,000	A	Dec 29, 2015	Dec 28, 2020	Common stock	25,000	2,020,983	I
Warrant^F1,F3	$0.65	Dec 29, 2015	P	25,000	A	Dec 29, 2015	Dec 28, 2020	Common stock	25,000	2,045,983	I
Warrant^F1,F4	$0.65	Dec 29, 2015	P	25,000	A	Dec 29, 2015	Dec 28, 2020	Common stock	25,000	2,070,983	I
Warrant^F1,F5	$0.65	Dec 29, 2015	P	25,000	A	Dec 29, 2015	Dec 28, 2020	Common stock	25,000	2,070,983	I
Convertible Note^F7,F6	—	Dec 31, 2015	C	1,019,985	D	—	—	Common stock	2,340,230	154,464	D
Warrant^F6	$0.65	Dec 31, 2015	C	849,987	A	Dec 31, 2015	Dec 30, 2020	Common stock	849,987	1,004,451	D
Warrant^F1	$0.65	Jan 25, 2016	P	12,599	A	Jan 25, 2015	Jan 24, 2021	Common stock	12,599	1,017,050	D
Warrant^F8	$0.715	Jan 27, 2016	J	208,112	A	Jan 27, 2016	Dec 28, 2020	Common stock	208,112	1,225,162	D

F1Units consisting of 2 shares and 1 warrant were purchased for $1.20 each.
F2Held by Michael Taglich C/F Hope Taglich UGMA
F3Held by Michael Taglich Cust. for Lucy Taglich UTMA NY
F4Held by Michael Taglich Custodian FBO Amanda Taglich UTMA NY Until Age 21
F5Held by Michael Taglich Custodian FBO Stella Taglich UTMA NY Until Age 21
F6Convertible notes were converted into equity and warrants as part of a note exchange offering. Each outstanding convertible note was converted into common stock at its conversion price, and each noteholder exercising notes also received warrants to purchase common stock in an amount equal to 50% of the total principal and interest converted, divided by 0.6.
F7N/A
F8Transaction Code J - Placement Agent warrants were issued at a rate of 10% of the shares sold by Taglich Brothers, Inc. on behalf of the Company, as part of a private placement of equity conducted by the Company in December 2015 and January 2016.