SEC Form 4 · accession 0001065949-15-000007
THREE FORKS, INC.
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
William F. Young
Other
Period of report
Nov 27, 2014
Accepted (ET)
Jan 13, 2015 · 8:57 pm EST
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0001548082
Table I — non-derivative securities
| Security | Date | Code | Shares | Price | A/D | Owned after | D/I | Nature of ownership |
|---|---|---|---|---|---|---|---|---|
| Common StockF1 | Nov 27, 2014 | J | 400,000 | — | D | 0 | D | |
| Common Stock | holding | — | — | — | 400,000 | D |
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| OptionsF2 | $0.10 | Nov 27, 2014 | J | 100,000 | D | Jun 13, 2013 | Jun 13, 2016 | Common Stock | 100,000 | 0 | D |
| Options | $0.10 | holding | — | — | — | Jun 13, 2013 | Jun 13, 2016 | Common Stock | 100,000 | 100,000 | D |
| Options | $1.00 | holding | — | — | — | Dec 15, 2013 | Dec 15, 2016 | Common Stock | 25,000 | 25,000 | D |
Explanation of responses
- F1Mr. Young surrendered to the Company 400,000 shares of common stock issued to him for immediate cancellation by the Company in connection with the Resignation and Settlement Agreement dated 11/27/2014.
- F2Mr. Young surrendered to the Company 100,000 of the $0.10 Options issued to him for immediate cancellation by the Company in connection with the Resignation and Settlement Agreement dated 11/27/2014.