- Annual Statement of Changes in Beneficial Ownership (5)
24 1월 2012 - 3:39AM
Edgar (US Regulatory)
FORM 5
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b).
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Form 3 Holdings Reported
[
X
]
Form 4 Transactions Reported
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0362
Expires:
January 31, 2014
Estimated average burden
hours per response...
1.0
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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(f) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person
*
Funk Werner
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2. Issuer Name
and
Ticker or Trading Symbol
Omnitek Engineering Corp [OMTK]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__
X
__ Director
__
X
__ 10% Owner
__
X
__ Officer (give title below)
_____ Other (specify below)
President; CEO; Secretary
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(Last)
(First)
(Middle)
1945 SOUTH RANCHO SANTE FE ROAD
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3. Statement for Issuer's Fiscal Year Ended
(MM/DD/YYYY)
12/31/2011
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(Street)
SAN MARCOS, CA 92078
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
_
X
_ Form Filed by One Reporting Person
___ Form Filed by More than One Reporting Person
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security
(Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code
(Instr. 8)
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4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I)
(Instr. 4)
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7. Nature of Indirect Beneficial Ownership
(Instr. 4)
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Amount
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(A) or (D)
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Price
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Common Stock
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8/19/2010
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A4
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5000
(1)
(2)
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A
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$
0.25
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8388992
(2)
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D
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Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (
e.g.
, puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 3)
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2. Conversion or Exercise Price of Derivative Security
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3. Trans. Date
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3A. Deemed Execution Date, if any
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4. Trans. Code
(Instr. 8)
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5. Number of Derivative Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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6. Date Exercisable and Expiration Date
(MM/DD/YYYY)
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7. Title and Amount of Securities Underlying Derivative Security
(Instr. 3 and 4)
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8. Price of Derivative Security
(Instr. 5)
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9. Number of Derivative Securities Beneficially Owned at End of Issuer's Fiscal Year
(Instr. 4)
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10. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
(Instr. 4)
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11. Nature of Indirect Beneficial Ownership
(Instr. 4)
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(A)
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(D)
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Date Exercisable
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Expiration Date
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Title
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Amount or Number of Shares
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Stock Options
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$
0.525
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11/8/2007
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11/7/2014
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Common Stock
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400000
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2000000
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D
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Stock Options
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$
0.625
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11/8/2008
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11/7/2014
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Common Stock
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400000
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2000000
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D
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Stock Options
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$
0.75
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11/8/2009
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11/7/2014
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Common Stock
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400000
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2000000
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D
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Stock Options
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$
0.875
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11/8/2010
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11/7/2014
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Common Stock
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400000
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2000000
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D
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Stock Options
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$
1
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11/8/2011
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11/7/2014
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Common Stock
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400000
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2000000
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D
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Explanation of Responses:
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(
1)
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On August 19, 2010, Mr. Funk purchased 5,000 shares of Omnitek common stock at $0.25 per share. There was no Form 4 filed and the Form 5 for the 2010 fiscal year failed to reflect this transaction in its totals.
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(
2)
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Mr. Funk held shares that were not accounted for in his initial Form 3 filed June 30, 2010, therefore all filings have failed to reflect these shares in their totals. As of December 31, 2011, Mr. Funk holds 8,388,992 shares of Omnitek.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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Funk Werner
1945 SOUTH RANCHO SANTE FE ROAD
SAN MARCOS, CA 92078
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X
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X
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President; CEO; Secretary
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Signatures
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Werner Funk
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1/23/2012
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 4(b)(v).
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**
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Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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Note:
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File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure.
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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.
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