SEC Form 4 · accession 0001683168-19-000478
QS Energy, Inc. · QSEP
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Jason B Lane
Officer — Chief Executive Officer · Director
Period of report
Feb 21, 2019
Accepted (ET)
Feb 21, 2019 · 5:45 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 | Feb 21, 2019 | A | — | A | Feb 21, 2019 | — | Common Stock | 550,000 | 4,362,492 | D |
| WarrantsF3 | $0.05 | Feb 21, 2019 | A | 275,000 | A | Feb 21, 2019 | Feb 21, 2020 | Common Stock | 275,000 | 4,637,492 | 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 Issuer.
- F2Not Applicable.
- F3Reporting Person acquired Issuer's Warrants as part of Reporting Person's purchase of Issuer's Convertible Note reported above.