SEC Form 4 · accession 0001144204-16-137769
INTELLINETICS, INC. · INLX
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Michael N Taglich
10% Owner
Period of report
Nov 30, 2016
Accepted (ET)
Dec 2, 2016 · 7:30 pm EST
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0001081745
Table I — non-derivative securities
No Table I lines on this filing.
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Warrant | $0.68 | Nov 30, 2016 | P | 25,000 | A | Nov 30, 2016 | Dec 1, 2021 | Common stock | 25,000 | 1,250,168 | D |
| Convertible NoteF3,F1,F2 | — | Nov 30, 2016 | P | — | A | Nov 30, 2016 | — | Common stock | — | 1,250,168 | D |
Explanation of responses
- F1Convertible Note is convertible into any equity securities next issued by the Company to investors on the same terms sold to other investors.
- F2N/A
- F3Total shares beneficially owned will be 1,250,168, plus any equity securities into which this note is convertible, based on as yet undetermined pricing.