SEC Form 4
| FORM 4 | UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP 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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| Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). | ||||||||||||||||
1. Name and Address of Reporting Person*
(Street)
| 2. Issuer Name and Ticker or Trading Symbol BEAR LAKE RECREATION INC [ BLKE ] | 5. Relationship of Reporting Person(s) to Issuer (Check all applicable)
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| 3. Date of Earliest Transaction (Month/Day/Year) 04/26/2017 | ||||||||||||||||||||||||||
| 4. If Amendment, Date of Original Filed (Month/Day/Year) | 6. Individual or Joint/Group Filing (Check Applicable Line)
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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) | 2. Transaction Date (Month/Day/Year) | 2A. Deemed Execution Date, if any (Month/Day/Year) | 3. Transaction Code (Instr. 8) | 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) | 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) | 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 7. Nature of Indirect Beneficial Ownership (Instr. 4) | |||
| Code | V | Amount | (A) or (D) | Price | ||||||
| Common Stock | 04/26/2017 | S | 181,633(2) | D | $0.022 | 104,083(1) | D | |||
| Common Stock | 04/26/2017 | S | 82,416(3) | D | $0.02 | 21,667 | D | |||
| Common Stock | 04/26/2017 | S | 6,667(4) | D | $0.02 | 15,000(5) | D | |||
| 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 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 Securities Underlying Derivative Security (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: Direct (D) or Indirect (I) (Instr. 4) | 11. Nature of Indirect Beneficial Ownership (Instr. 4) | ||||
| Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||||||
| Explanation of Responses: |
| 1. These shares reflect a 3.5 for 1 reverse stock split effective October 23, 2006. The previous ownership reported was 1,000,000 shares beneficially owned, which after the reverse and rounding equals 285,716 shares beneficially owned. |
| 2. 181,633 shares were cancelled to the Company for an aggregate price of $4,000 pursuant to a Common Stock Purchase Agreement dated April 5, 2017 (the "Agreement"), and filed with the Securities and Exchange Commission on that date; the Agreement was closed and completed on April 26, 2017, at which time Mr. Albiston's resignation as an officer and director became effective. |
| 3. Mr. Albiston sold 82,416 shares to a person who may be deemed to have been a related party of the Company at $0.02 per share for an aggregate purchase price of $1,648.32. |
| 4. Mr. Albiston sold 6,667 shares to a former legal counsel of the Company at $0.02 per share for an aggregate purchase price of $133.34. |
| 5. The Agreement required that the remaining 15,000 shares owned by Mr. Albiston be pledged to the Company for a period of 12 months under an Indemnification Escrow Agreement and an Indemnification Agreement. |
| Remarks: |
| The Agreement required that the remaining 15,000 shares owned by Mr. Albiston be pledged to the Company for a period of 12 months under an Indemnification Escrow Agreement and an Indemnification Agreement. |
| /s/ Derrick Albiston | 04/27/2017 | |
| ** Signature of Reporting Person | Date | |
| Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | ||
| * 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). | ||
| Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. | ||
| 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 Number. | ||