SEC Form 3
FORM 3 | UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES 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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1. Name and Address of Reporting Person*
(Street)
| 2. Date of Event Requiring Statement (Month/Day/Year) 03/21/2018 | 3. Issuer Name and Ticker or Trading Symbol Long Blockchain Corp. [ LBCC ] | |||||||||||||
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
| 5. 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 Beneficially Owned | |||
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1. Title of Security (Instr. 4) | 2. Amount of Securities Beneficially Owned (Instr. 4) | 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 4. Nature of Indirect Beneficial Ownership (Instr. 5) |
Common Stock | 1,949,736 | D(1) | (1) |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
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1. Title of Derivative Security (Instr. 4) | 2. Date Exercisable and Expiration Date (Month/Day/Year) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 6. Nature of Indirect Beneficial Ownership (Instr. 5) | ||
Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Explanation of Responses: |
1. TSLC Pte. Ltd. ("TSLC") acquired 1,949,736 shares of common stock of the issuer pursuant to that certain Contribution and Exchange Agreement dated as of March 21, 2018. TSLC is majority owned by Aark Singapore Pte. Ltd. ("Aark"), and Mr V. Raman Kumar ("Mr. Kumar", collectively with TSLC and Aark, the "Reporting Persons") controls Aark. Aark and Mr. Kumar are indirect beneficial owners of the reported securities. Each of the Reporting Persons disclaims a pecuniary interest in the reported securities held by any other Reporting Person except to the extent of its pecuniary interest in such reported securities. Aark's address is 583 Orchard Road, #06-01 Forum, Singapore 238884. Mr. Kumar's business address is Office 2705, API Trio Tower O, Sheikh Zayed Road, Dubai, United Arab Emirates. Mr. Kumar signs in his individual capacity and on behalf of each of TSLC and Aark in his capacity as Chairman of each entity. |
/s/ V. Raman Kumar | 04/02/2018 | |
** 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 5 (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. |