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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 (4) | $ 0.04 | 09/29/2011 | C | 237,500 | 09/29/2011 | (4) | Common Shares | 237,500 | (4) | 0 | D |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Fagen Patrick 103-318 NORTH CARSON STREET CARSON CITY, NV 89703 |
X | Chief Financial Officer |
Patrick Fagen | 10/03/2011 | |
**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) | These shares are held indirectly by Patrick Fagen through his Grant Fagen Custodial Account. |
(2) | These shares are held indirectly by Patrick Fagen through his IRA account. |
(3) | On September 29, 2011, Patrick Fagen purchase 716,298 common shares through the Issuer's private placement at an issuance price of $0.04 per share. |
(4) | On September 29, 2011, the Issuer and Patrick Fagen entered into a debt settlement and subscription agreement wherein Mr. Fagen agreed to subscribe for 237,500 shares of common stock of the Issuer at a purchase price of $0.04 per share, or $9,500, exercisable on demand. In lieu of a cash payment to the Issuer, the shares of common stock were issued to Mr. Fagen as payment of an outstanding debt owed to Mr. Fagen in the amount of $9,500, as full payment of the debt owed. |