Amended Annual Statement of Changes in Beneficial Ownership (5/a)
04 5월 2016 - 7:00AM
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
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 or Section 30(h) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person
*
ARENS GEOFFREY W
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2. Issuer Name
and
Ticker or Trading Symbol
VISCOUNT SYSTEMS INC [VSYS]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__
X
__ Director
__
X
__ 10% Owner
_____ Officer (give title below)
_____ Other (specify below)
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(Last)
(First)
(Middle)
C/O DENDERA CAPITAL FUND LP, 747 THIRD AVE, 26TH FLOOR
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3. Statement for Issuer's Fiscal Year Ended
(MM/DD/YYYY)
12/31/2015
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(Street)
NEW YORK, NY 10017
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
2/18/2016
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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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3/5/2015
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D4
(1)
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2925000
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D
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(1)
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1361111
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I
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By Dendera Capital Fund LP
(2)
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Series B Preferred Stock
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11/3/2015
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A4
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10.865
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A
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(3)
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10.865
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I
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By Dendera Capital Fund LP
(2)
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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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Series A Note
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$0.009
(4)
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9/22/2015
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C4
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1
(5)
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9/22/2015
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(6)
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Common Stock
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40459924
(7)
(8)
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(9)
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1
(5)
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I
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By Dendera Capital Fund LP
(2)
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Series A Note
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$0.009
(4)
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11/3/2015
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P4
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1
(10)
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11/3/2015
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(6)
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Common Stock
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47820199
(7)
(8)
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$110000
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1
(10)
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I
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By Dendera Capital Fund LP
(2)
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Series B Note
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$0.009
(4)
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11/3/2015
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P4
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1
(10)
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11/3/2015
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(6)
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Common Stock
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12141280
(7)
(8)
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$110000
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1
(10)
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I
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By Dendera Capital Fund LP
(2)
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Series A Note
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$0.009
(4)
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11/3/2015
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J4
(11)
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1
(11)
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11/3/2015
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(6)
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Common Stock
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577911
(7)
(8)
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(10)
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1
(11)
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I
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By Dendera Capital Fund LP
(2)
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Series A Note
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$0.009
(4)
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12/31/2015
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J4
(12)
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1
(12)
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12/31/2015
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(6)
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Common Stock
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5907968
(7)
(8)
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(12)
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1
(12)
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I
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By Dendera Capital Fund LP
(2)
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Series B Note
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$0.009
(4)
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12/31/2015
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J4
(13)
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1
(13)
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12/31/2015
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(6)
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Common Stock
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2433939
(7)
(8)
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(13)
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1
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I
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By Dendera Capital Fund LP
(2)
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Explanation of Responses:
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(
1)
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The issuer issued to Dendera Capital Fund LP ("Dendera") (whose principal is Geoffrey Arens, a director of the issuer) 2,925,000 shares of common stock of the issuer, par value $0.001 per share (the "Common Stock"), on January 20, 2015. The issuer intended to issue to Dendera 200 shares of Series A Convertible Redeemable Preferred Stock of the Company (the "A Shares"). The issuer rectified this error by issuing to Dendera 200 A Shares. This curative transaction is exempt from Section 16(b) of the Securities Exchange Act of 1934, as amended (the "Exchange Act"), pursuant to the exemptions set forth under Exchange Act Rule 16(b)-3(e), and is being reported herein to amend the reporting person's Form 4 filed with the SEC on March 5, 2015 to disclose the disposition of such Common Stock to the issuer upon the issuance of the 200 A Shares to the reporting person.
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(
2)
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The reporting person is the managing partner of and 100% interest holder of Dendera.
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(
3)
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In connection with a financing for general company purposes, including, but not limited to, working capital and operating expenses, Dendera was also issued Series B Preferred Stock of the Company (the "B Shares"). Holders of B Shares do not have conversion rights or dividend rights.
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(
4)
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The conversion price of each of the 14% Senior Secured Convertible Demand Promissory A Note (each, a "Series A Note") and the Senior Secured Convertible Demand Promissory B Note (the "Series B Note") is subject to adjustment upon issuance of certain dividends and distributions, reorganization, consolidation or merger, stock splits, and issuance by the issuer of a security at a lower price than each such conversion price.
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(
5)
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Upon conversion of the A Shares, Dendera was issued a Series A Note in the aggregate original principal amount of $323,251. Such principal amount was incorrectly disclosed in footnote 10 of the reporting person's Form 5 filed with the U.S. Securities and Exchange Commission on February 18, 2016 (the "Original Filing") as $433,251. The issuance of the remaining $110,000 is disclosed herein as an issuance to Dendera of a separate Series A Note in the original principal amount of $110,000 as disclosed in footnote 10 below.
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(
6)
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Each of the Series A Notes and Series B Note may be converted (subject to certain beneficial ownership limitations), at the option of the holder at any time and from time to time, into shares of Common Stock.
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(
7)
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Pursuant to each of the Series A Notes and Series B Note, Dendera shall not convert each Series A Note or Series B Note if such conversion results in Dendera beneficially owning more than 4.99% of the shares of Common Stock. The holder has the option to waive either of these limitations upon 61 days' notice to the issuer.
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(
8)
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The number of shares reported represent the number of shares of Common Stock that would be issued upon conversion of the Series A Note or Series B Note, as applicable, as of the date of such Series A Note or Series B Note dividends.
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(
9)
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On September 22, 2015, in exchange for conversion of the 212.01 A Shares held by Dendera as of such date, the issuer issued to Dendera a Series A Note. The transaction reported herein is intended to amend (i) the date of conversion of such A Shares from November 3, 2015 to September 22, 2015 and (ii) the amount of Common Stock issuable upon conversion of such Note, each as reported in the Original Filing.
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(
10)
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In connection with a financing for general company purposes, including, but not limited to, working capital and operating expenses, Dendera was issued a Series A Note and a Series B Note, each in the original principal amount of $110,000. The original principal amount of the Series B Note reported herein is intended to amend such amount reported in the Original Filing from $270,000 to $110,000.
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(
11)
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Interest paid in a Series A Note issued to Dendera pursuant to the Series A Note which increased the amount due under such Series A Note by $5,236.
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(
12)
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Interest paid in a Series A Note issued to Dendera pursuant to the Series A Note which increased the amount due under such Series A Note by $42,891.85.
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(
13)
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Interest paid in Series B Note issued to Dendera pursuant to the Series B Note which increased the amount due under such Series B Note by $17,670.40.
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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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ARENS GEOFFREY W
C/O DENDERA CAPITAL FUND LP
747 THIRD AVE, 26TH FLOOR
NEW YORK, NY 10017
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X
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X
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Signatures
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/s/ Geoffrey W. Arens
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5/3/2016
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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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