SEC Form 4 · accession 0001683168-19-000527
QS Energy, Inc. · QSEP
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Richard William Munn
Director
Period of report
Jan 1, 2019
Accepted (ET)
Mar 1, 2019 · 2:03 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|
| OptionsF1 | $0.08 | Jan 1, 2019 | A | 625,000 | A | — | Jan 1, 2029 | Common Stock | 625,000 | 1,152,778 | D |
| Convertible NoteF2,F3 | $0.05 | Feb 25, 2019 | A | — | A | Feb 25, 2019 | — | Common Stock | 220,000 | 1,372,778 | D |
| WarrantsF4 | $0.05 | Feb 25, 2019 | A | 110,000 | A | Feb 25, 2019 | Feb 25, 2020 | Common Stock | 110,000 | 1,482,778 | D |
Explanation of responses
- F1The stock options reported under item 1 above were granted to Reporting Person as equity compensation under Issuer's Board Compensation Policy, approved by the Board on 6/19/2015. The options vest at the rate of 1/12 per month, commencing 1/1/2019, with full vesting on 12/31/2019.
- F2Reporting Person acquired Issuer's Convertible Note in the principal amount of $11,000, for a purchase price of $10,000, convertible into 220,000 shares of common stock of Issuer.
- F3Not Applicable.
- F4Reporting Person acquired Issuer's Warrants as part of Reporting Person's purchase of Issuer's Convertible Note reported above.