SEC Form 4 · accession 0001683168-17-001326
QS Energy, Inc. · QSEP
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Richard William Munn
Director
Period of report
May 15, 2017
Accepted (ET)
May 17, 2017 · 4:54 pm EDT
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 Stock | May 15, 2017 | P | 42,000 | $0.24 | A | 42,000 | D | |
| Common Stock | May 15, 2017 | C | 220,000 | $0.05 | A | 262,000 | D |
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 | May 15, 2017 | A | — | A | May 15, 2017 | — | Common Stock | 220,000 | 470,000 | D |
| WarrantsF3 | $0.05 | May 15, 2017 | A | 110,000 | A | May 15, 2017 | May 15, 2018 | Common Stock | 110,000 | 580,000 | D |
| Convertible NoteF4,F2 | $0.05 | May 15, 2017 | D | — | D | — | — | Common Stock | 220,000 | 360,000 | D |
Explanation of responses
- F1Reporting Person acquired Issuer's Convertible Note in the principal amount of $11,000, for a purchase price of $10,000, convertible into 220,000 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.
- F4Reporting Person converted the Convertible Note listed above and described in Footnote 1 of this Form 4.