SEC Form 4 · accession 0001493152-17-014094
INTELLINETICS, INC. · INLX
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Robert Taglich
10% Owner
Period of report
Nov 29, 2017
Accepted (ET)
Dec 1, 2017 · 5:30 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Convertible NoteF1 | $0.30 | Nov 29, 2017 | C | — | D | Sep 21, 2017 | — | Common stock | 257,733 | 1,328,572 | D |
| Convertible NoteF2,F1 | $0.20 | Nov 29, 2017 | C | 75,000 | A | Nov 29, 2017 | — | Common stock | 375,000 | 1,703,572 | D |
Explanation of responses
- F1N/A
- F2$75,000 in convertible notes, exercisable at $0.20 per share, were purchased by the surrender and cancellation of $77,320 in convertible notes, exercisable at $0.30 per share, as set forth above. Outstanding interest on the previously-issued convertible notes was paid in full in cash.