SEC Form 4 · accession 0001683168-17-000972
QS Energy, Inc. · QSEP
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Eric Bunting
Director
Period of report
Apr 17, 2017
Accepted (ET)
Apr 18, 2017 · 2:33 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 | $0.05 | Apr 18, 2017 | A | 55,000 | A | Apr 18, 2017 | — | Common Stock | 1,100,000 | 1,635,714 | D |
| WarrantsF3 | $0.05 | Apr 18, 2017 | A | 55,000 | A | Apr 18, 2017 | Apr 18, 2018 | Common Stock | 550,000 | 2,185,714 | D |
Explanation of responses
- F1Reporting Person acquired Issuer's Convertible Note in the principal amount of $55,000, for a purchase price of $50,000, convertible into 1,100,000 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.