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 QLT INC/BC [ QLTI ] | 5. Relationship of Reporting Person(s) to Issuer (Check all applicable)
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3. Date of Earliest Transaction (Month/Day/Year) 06/17/2016 | ||||||||||||||||||||||||||
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 |
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 | ||||||||
Stock Option (right to buy) | $1.43(1) | 06/17/2016 | A | 50,000 | (2) | 06/17/2026 | Common stock | 50,000 | $0 | 50,000 | D | ||||
Phantom Stock(3) | (4) | 06/17/2016 | A | 6,400 | (5) | (6) | Common stock | 6,400 | $0 | 28,400(7) | D |
Explanation of Responses: |
1. Option exercise price reflects the closing price of the Issuer's common stock on the NASDAQ Stock Market on the June 17, 2016 grant date. |
2. The options vest and become exercisable in thirty-six (36) successive and equal monthly installments from the June 17, 2016 grant date. These options were awarded pursuant to the Issuer's 2000 Incentive Stock Plan, as amended and restated. |
3. Deferred Stock Units ("DSUs") are payable in cash. The DSUs were awarded pursuant to the Issuer's Directors' Deferred Share Unit Plan. |
4. Each DSU, when converted to cash, will be equivalent to the market value of one share of the Issuer's common stock at the time the conversion takes place. |
5. The DSUs vest in thirty-six (36) successive and equal monthly installments beginning on the first day of the first month after the June 17, 2016 grant date. |
6. The DSUs have no fixed expiration date. Any vested DSUs are payable in cash upon the Reporting Person's departure from the Board of Directors of the Issuer, with any unvested DSUs expiring on such date. |
7. Reflects the aggregate amount of DSUs granted to the Reporting Person to date, of which 21,694 DSUs have vested. |
/s/ Dori Assaly, as Attorney-in-Fact | 06/21/2016 | |
** 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. |