SEC Form 4 · accession 0001094891-15-000371
Long Blockchain Corp. · LBCC
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
KA No. 2 Trustee Ltd
10% Owner
Period of report
Dec 23, 2015
Accepted (ET)
Dec 28, 2015 · 11:53 am EST
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0001629261
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 Promissory NoteF1,F3,F2 | $4.00 | Dec 23, 2015 | J | — | A | Nov 23, 2015 | — | Common Stock | 386 | — | I |
Explanation of responses
- F1Represents monthly interest earned on the principal balance of the Convertible Promissory Note, which was paid in-kind by adding it to the principal balance of the note. The Convertible Promissory Note was issued in consideration of a loan made by Brentwood LIIT Inc. to Long Island Brand Beverages LLC, the issuer's wholly owned subsidiary.
- F2All or any portion of the outstanding principal balance of the Convertible Promissory Note, and all accrued and unpaid interest thereon, are convertible, at the option of Brentwood LIIT Inc., into shares of the issuer's common stock. The loan, evidenced by the Convertible Promissory Note, matures on November 23, 2018.
- F3The reporting person disclaims beneficial ownership of these securities, except to the extent of its pecuniary interest therein, and this report shall not be deemed an admission that the reporting person is the beneficial owner of the securities for purposes of Section 16 or for any other purpose.