SEC Form 4 · accession 0001683168-18-000921
QS Energy, Inc. · QSEP
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
A later amendment supersedes this filing — read the amendment. The figures below are kept as originally reported (version chain, not an overwrite).
Reporting owner
Eric Bunting
Director
Period of report
Mar 30, 2018
Accepted (ET)
Apr 4, 2018 · 4:11 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 | Apr 2, 2018 | C | 225,000 | $0.08 | A | 8,239,530 | D | |
| Common StockF5 | Apr 2, 2018 | C | 550,000 | $0.08 | A | 8,789,530 | 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 | $0.08 | Mar 30, 2018 | A | — | A | Mar 30, 2018 | — | Common Stock | 550,000 | 827,778 | D |
| WarrantsF3 | $0.08 | Mar 30, 2018 | A | 225,000 | A | Mar 30, 2018 | Mar 30, 2019 | Common Stock | 225,000 | 1,052,778 | D |
| WarrantsF4 | $0.08 | Apr 2, 2018 | C | 225,000 | D | Apr 2, 2018 | Mar 30, 2019 | Common Stock | 225,000 | 827,778 | D |
| Convertible NoteF5,F2 | $0.08 | Apr 2, 2018 | C | 550,000 | D | Apr 2, 2018 | — | Common Stock | 550,000 | 277,778 | D |
Explanation of responses
- F1Reporting Person acquired Issuer's Convertible Note in the principal amount of $44,000, for a purchase price of $40,000, convertible into 550,000 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 Issuer's Warrants received as part of Reporting Person's purchase of Issuer's Convertible Note acquired on 3/30/2018.
- F5Reporting Person converted the Convertible Note reported above.