SEC Form 4 · accession 0001683168-17-002564
QS Energy, Inc. · QSEP
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Eric Bunting
Director
Period of report
May 1, 2017
Accepted (ET)
Oct 3, 2017 · 5:12 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 StockF1 | May 1, 2017 | C | 1,100,000 | $0.05 | A | 7,835,430 | D |
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Convertible NoteF2,F3,F1 | $0.05 | May 1, 2017 | C | 1,100,000 | D | Apr 18, 2017 | — | Common Stock | 1,100,000 | 179,710 | D |
Explanation of responses
- F1Total Numbers of Securities and Derivative Securities Beneficially Owned are as of the date of this report, 10/2/2017, not the date of the transaction.
- F2Reporting Person converted Issuer's Convertible Note acquired on 4/18/2017. This conversion was executed by Reporting Person on 05/01/2017, but not previously reported.
- F3Reporting Person acquired Issuer's Convertible Note in the principal amount of $55,000, for a purchase price of $50,000.