SEC Form 4 · accession 0001683168-18-003579
QS Energy, Inc. · QSEP
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Don Dickson
Director
Period of report
Nov 26, 2018
Accepted (ET)
Nov 28, 2018 · 6:06 pm EST
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 | Nov 26, 2018 | A | — | A | Nov 26, 2018 | — | Common Stock | 550,000 | 2,561,759 | D |
| WarrantsF3 | $0.05 | Nov 26, 2018 | A | 275,000 | A | Nov 26, 2018 | Nov 26, 2019 | Common Stock | 275,000 | 2,836,759 | D |
Explanation of responses
- F1Reporting Person acquired Issuer's Convertible Note in the principal amount of $27,500, for a purchase price of $25,000, convertible into 550,000 shares of common stock of the Issuer.
- F2Not Applicable.
- F3Reporting Person acquired Issuer's Warrants as part of Reporting Person's purchase of Issuer's Convertible Note reported above.