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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, Subordinated, Unsecured Promissory Note | $ 0.5 | 11/08/2016 | A | 100,000 | 11/08/2016 | 11/08/2019 | Noble Roman's Inc | 300,000 | $ 0.5 (1) | 1,573,333 | D | ||||
Convertible, Subordinated, Unsecured Promissory Note | $ 0.5 | 12/16/2016 | A | 50,000 | 12/29/2016 | 12/29/2019 | Noble Roman's Inc | 150,000 | $ 0.5 (1) | 1,723,777 | D |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
MOBLEY PAUL W ONE VIRGINIA AVENUE, SUITE 300 INDIANAPOLIS, IN 46204 |
Executive Chairman | Executive Chairman |
/s/Paul Mobley | 04/10/2017 | |
**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) | Interest on the notes accrues at the annual rate of 10% payable quarterly in arrears. Principal of the notes matures three years after issuance. Each holder of the notes may convert them at any time during the term of the notes into common stock of the company at a conversion rate of $.50 per share. Also with the notes are warrants which may be redeemed for common stock of the company at the exercise price of $1.00 per share. The warrants expire at the end of three years. |