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 Petrolia Energy Corp [ BBLS ] | 5. Relationship of Reporting Person(s) to Issuer (Check all applicable)
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3. Date of Earliest Transaction (Month/Day/Year) 07/12/2018 | ||||||||||||||||||||||||||
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 Shares (Restricted) | 07/12/2018 | P | 500,000(1) | A | $0.065 | 1,416,667 | I | American Resources Offshore Inc. | ||
Common Shares | 10/03/2018 | P | 468,750(1) | A | $0.065 | 1,885,417 | I | American Resources Offshore Inc. | ||
Common Shares | 11/02/2018 | P | 547,755(2) | A | $0.064 | 2,433,171 | I | American Resources Offshore Inc. | ||
Common Shares | 12/19/2018 | A | 156,250(3) | A | $0.08 | 2,041,667 | I | American Resources Offshore Inc. | ||
Common Shares | 01/15/2019 | A | 1,000,000(4) | A | $0.05 | 3,589,421 | I | American Resources Offshore Inc. |
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 | ||||||||
Warrant | $0.1 | 08/17/2018 | A | 20,000(6)(8) | 08/17/2018 | 08/17/2019 | Common Stock | 20,000 | $0.1 | 686,667 | I | American Resources Offshore Inc. | |||
Warrant | $0.1 | 09/30/2018 | A | 250,000(5)(8) | 09/30/2018 | 09/30/2020 | Common Stock | 250,000 | $0.1 | 936,667 | D | ||||
Warrant | $0.1 | 12/14/2018 | A | 312,500(3)(8) | 12/14/2018 | 11/01/2020 | Common Stock | 312,500 | $0.1 | 1,249,167 | I | American Resources Offshore Inc. | |||
Warrant | $0.1 | 12/31/2018 | A | 250,000(5)(8) | 12/31/2018 | 12/31/2020 | Common Stock | 250,000 | $0.1 | 1,499,167 | D | ||||
Warrant | $0.1 | 03/31/2019 | A | 250,000(7)(8) | 03/31/2019 | 03/31/2021 | Common Stock | 250,000 | $0.1 | 1,749,167 | D |
Explanation of Responses: |
1. Mr. Siem acquired these shares in a private third-party transaction at a market value of $0.065/share. |
2. Mr. Siem acquired these shares in a private third-party transaction at a market value of $0.064/share. |
3. Mr. Siem indirectly participated in Private Placement #4 at $0.08/share, participants also received 2x warrants for every share, exercisable for 2 years. |
4. Mr. Siem acquired these shares in a private third-party transaction at a market value of $0.05/share. |
5. Mr. Siem receives a 250,000-warrant issuance quarterly as part of his compensation 2018 compensation package for his service on the Board; exercisable for a 24 months period. |
6. Mr. Siem indirectly participated in a Bridge Loan for $20,000 in August 2018, as part of the compensation for the loan participants received an interest rate of 12% simple interest and one (1) warrant for every dollar loaned; exercisable for one year. |
7. Mr. Siem receives a 250,000-warrant issuance quarterly as part of his compensation 2019 compensation package for his service on the Board; exercisable for a 24 months period. |
8. Each Warrant unit represents a contingent right to receive one share of Petrolia's common stock. |
/s/ Ivar Siem | 05/10/2019 | |
** 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. |