SEC Form 4 · accession 0001683168-17-000190
QS Energy, Inc. · QSEP
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Don Dickson
Director
Period of report
Oct 13, 2016
Accepted (ET)
Jan 30, 2017 · 3:25 pm EST
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0001103795
Table I — non-derivative securities
| Security | Date | Code | Shares | Price | A/D | Owned after | D/I | Nature of ownership |
|---|---|---|---|---|---|---|---|---|
| Common StockF1 | Oct 13, 2016 | C | 770,000 | $0.10 | A | 784,620 | D |
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Conversion of NoteF1 | $0.10 | Oct 13, 2016 | C | 770,000 | D | Aug 5, 2016 | — | Common Stock | 770,000 | 841,203 | D |
| Option to Purchase Common StockF2 | $0.05 | Jan 1, 2017 | A | 1,000,000 | A | Jan 1, 2017 | Jan 1, 2027 | Common Stock | 1,000,000 | 1,841,203 | D |
Explanation of responses
- F1Common Stock purchased on 10/13/2016 pursuant to Issuer's Convertible Note, purchased by Reporting Person on 08/05/2016 in the principal amount of $77,000, for a purchase price of $70,000, convertible into 770,000 shares of common stock of Issuer.
- F2The stock options reported under item 1 above were granted to each member of Issuer's Board as equity compensation under the Issuer's Board Compensation Policy, approved by the Board on 06/19/2015. The options granted under item 1 vest at the rate of 1/12 per month, commencing 01/01/2017, with full vesting on 12/31/2017.