SEC Form 4 · accession 0001683168-17-001913
QS Energy, Inc. · QSEP
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Don Dickson
Director
Period of report
Jul 30, 2017
Accepted (ET)
Aug 1, 2017 · 12:59 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 | Jul 30, 2017 | C | 385,000 | $0.10 | A | 1,169,620 | D |
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| WarrantsF1 | $0.10 | Jul 30, 2017 | C | 385,000 | D | Aug 5, 2016 | Aug 4, 2017 | Common Stock | 385,000 | 1,456,203 | D |
Explanation of responses
- F1Reporting Person converted Issuer's Warrants received as part of Reporting Person's purchase of Issuer's Convertible Note acquired on 8/5/2016.