SEC Form 4 · accession 0001019687-16-007106
QS Energy, Inc. · QSEP
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Don Dickson
Director
Period of report
Aug 5, 2016
Accepted (ET)
Aug 8, 2016 · 4:51 pm EDT
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0001103795
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,F2 | $0.10 | Aug 5, 2016 | A | 70,000 | A | Aug 5, 2016 | — | Common Stock | 770,000 | 1,226,203 | D |
| WarrantsF3 | $0.10 | Aug 5, 2016 | A | 385,000 | A | Aug 5, 2016 | Aug 4, 2017 | Common Stock | 385,000 | 1,611,203 | D |
Explanation of responses
- F1Reporting Person acquired Issuer's Convertible Note in the principal amount of $77,000, for a purchase price of $70,000, convertible into 770,000 shares of common stock of Issuer.
- F2Not applicable.
- F3Reporting Person acquired Issuer's Warrants as part of Reporting Person's purchase of Issuer's Convertible Note reported above.