SEC Form 5 · accession 0001493152-16-007549
VISCOUNT SYSTEMS INC · VSYS
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Ned L Siegel
Director · Other
Period of report
Dec 31, 2015
Accepted (ET)
Feb 19, 2016 · 4:58 pm EST
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0001158387
Table I — non-derivative securities
| Security | Date | Code | Shares | Price | A/D | Owned after | D/I | Nature of ownership |
|---|---|---|---|---|---|---|---|---|
| Common StockF2 | Dec 12, 2014 | P | 80,645 | $5,052.18 | A | 706,500 | D | |
| Common StockF3 | Dec 22, 2014 | P | 110,000 | $9,955.75 | A | 816,500 | D | |
| Common Stock | Feb 18, 2015 | J | 15,950 | $1,054.22 | A | 832,450 | D | |
| Common StockF5 | Dec 23, 2015 | A | 1,000,000 | — | A | 1,832,450 | D | |
| Common StockF1 | holding | — | — | — | 625,855 | D |
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| WarrantF6 | $0.09 | Apr 14, 2014 | A | 250,000 | A | Apr 14, 2014 | Apr 14, 2017 | Common Stock | 250,000 | 777,777 | D |
| WarrantF7 | $0.14 | Mar 6, 2015 | J | 7,975 | A | Mar 6, 2015 | Mar 6, 2020 | Common Stock | 7,975 | 785,752 | D |
| WarrantF1 | $0.20 | holding | — | — | — | Mar 11, 2014 | Mar 11, 2019 | Common Stock | 277,777 | 277,777 | D |
| WarrantF1 | $0.09 | holding | — | — | — | Apr 4, 2014 | Apr 4, 2017 | Common Stock | 250,000 | 527,777 | D |
Explanation of responses
- F1Represents the amount of securities of the issuer held by the reporting person as of April 4, 2014, the date on which the reporting person was appointed to the board of directors of the issuer.
- F2The common stock of the issuer (the "Common Stock") purchased by the reporting person is being reported herein to amend the amount of Common Stock beneficially owned as listed in the reporting person's Form 4 filed with the U.S. Securities and Exchange Commission (the "SEC") on December 12, 2014.
- F3The Common Stock purchased by the reporting person is being reported herein to amend the amount of Common Stock beneficially owned as listed in the reporting person's Form 4 filed with the SEC on December 23, 2014.
- F4Common Stock issued to the reporting person in connection with a private placement conducted by the issuer as reported in the issuer's Current Report on Form 8-K ("Form 8-K") filed with the U.S. Securities and Exchange Commission (the "SEC") on January 21, 2015.
- F5Restricted Common Stock granted to the reporting person for $0 as approved by the issuer's compensation committee. The Common Stock shall fully vest one year from the date of grant.
- F6Warrants to purchase shares of Common Stock granted by the issuer to the reporting person for serving as a director of the issuer pursuant to a compensation warrant agreement between the reporting person and the issuer.
- F7On February 18, 2015, pursuant to the private placement reported in the issuer's Form 8-K filed with the SEC on January 21, 2015, the reporting person purchased 15,950 shares of Common Stock listed above and this warrant to purchase 7,975 shares of Common Stock for no additional consideration.