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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | |||
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB control number. | SEC 1474 (9-02) |
1. Title of Derivative Security (Instr. 3) |
2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) |
5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4, and 5) |
6. Date Exercisable and Expiration Date (Month/Day/Year) |
7. Title and Amount of Underlying Securities (Instr. 3 and 4) |
8. Price of Derivative Security (Instr. 5) |
9. Number of Derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) |
10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
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Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||||||
Convertible Note | $ 0.1 (1) | 01/27/2012 | A | 50,000 | 01/27/2012 | 06/24/2012 | Common Stock | 500,000 | (2) | 50,000 | I | By LLLP | |||
Convertible Note | $ 0.1 (1) | 01/27/2012 | C | 50,000 | 01/27/2012 | 06/24/2012 | Common Stock | 500,000 | (2) | 0 | I | By LLLP | |||
Series A Convertible Preferred Stock | (3) | 01/27/2012 | C | 100,000 | (3) | (3) | Common Stock | 500,000 | (2) | 100,000 | I | By LLLP | |||
Common Stock Warrants | $ 0.2 (1) | 01/27/2012 | A | 500,000 | 01/27/2012 | 06/24/2016 | Common Stock | 500,000 | (2) | 500,000 | I | By LLLP |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Feirstein Douglas 330 SW 2ND STREET SUITE 209 FORT LAUDERDALE, FL 33312 |
X | Chief Executive Officer |
/s/ Douglas Feirstein | 01/30/2012 | |
**Signature of Reporting Person | Date |
* | If the form is filed by more than one reporting person, see Instruction 4(b)(v). |
** | Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). |
(1) | The exercise or conversion price assumes the completion of a reverse stock split in which the issuer's outstanding common stock is reduced to approximately 10,000,000 shares. |
(2) | In connection with a $50,000 loan, the reporting person was issued a convertible note. The reporting person acquired the Series A upon converting a $50,000 note. The warrants were issued in connection with the loan. The exercise price of the securities was contingent on the closing of a future financing. The financing closed on January 27, 2012. |
(3) | Each share of Series A will automatically convert into five shares of the issuer's common stock at a future event which requires shareholder approval. The Series A will expire at the time of conversion. |