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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 | ||||||||
Common Stock Options | $ 0.05 | 02/01/2007 | A | 5,000 (1) | 02/02/2007 | 01/31/2017 | Common Stock | 5,000 | $ 0.05 | 5,000 | D | ||||
Common Stock Options | $ 0.1 | 11/07/2009 | A | 20,000 | 11/08/2009 | 11/06/2019 | Common Stock | 20,000 | $ 0.1 | 25,000 | D |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Sample Gwendolyn G 3512 E. SILVER SPRINGS BLVD - #243 OCALA, FL 34470 |
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/s/ Gwendolyn G Sample | 01/19/2010 | |
**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) | Common Stock Options awarded 02/01/2007, but not reported in timely manner. The Company reported this transaction in Item 13 of its 10-K Annual Reports in 2007 and 2008, but Reporting Person inadvertently failed to report the Options on Form 3 or Form 4 as required. |
Remarks: Common Stock Options issued to Reporting Person for service as Assistant Secretary of the Corporation and for accounting services provided to the Company. See Footnote #1 regarding Reporting Person's inadvertent failure to timely file notice of grant of Common Stock Options on Form 3 or Form 4 in February of 2007. Reporting Person disclaims any beneficial ownership in securities held by her spouse or others, and further disclaims any beneficial ownership in her securities by her spouse or other persons. |