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) 04/18/2017 | ||||||||||||||||||||||||||
4. If Amendment, Date of Original Filed (Month/Day/Year) 06/15/2017 | 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 | 1,550,000 | 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 | ||||||||
Series A Convertible Preferred Stock | $0.14 | 05/26/2017 | A | 10,500 | 05/26/2017 | (1) | Common Stock | 750,000 | $10 | 10,500 | D | ||||
Series A Convertible Preferred Stock | $0.14 | 05/23/2017 | A | 3,000 | 05/23/2017 | (1) | Common Stock | 214,286 | $10 | 13,500 | D | ||||
Series A Convertible Preferred Stock | $0.14 | 04/18/2017 | A | 2,900 | 04/18/2017 | (1) | Common Stock | 207,143 | $10 | 16,400 | D |
Explanation of Responses: |
1. The Issuer's Series A Convertible Preferred Stock have a face value of $10 per share and convert into common stock of the Issuer (along with any accrued dividends thereon), at any time at the option of the holder thereof, and automatically when the Issuer's common stock market price equals or exceeds $0.30 per share for 30 consecutive days, at a conversion price of $0.14 per share (each share of preferred stock converts into 71.42 shares of common stock). The Series A Convertible Preferred Stock also accrues a cumulative dividend at a rate of 9% per annum and includes a blocker, preventing the conversion of such preferred stock into common stock if upon such conversion the holder would hold more than 4.99% of the Issuer's outstanding common stock. |
Remarks: |
This Form 4/A is being filed to correct certain errors in the disclosure of the preferred stock acquired by the Reporting Person as reported herein and move the preferred stock from the Non-Derivative Security table to the Derivative Security table due to the conversion terms thereof. This Form 4/A also corrects the earliest transaction date reported. |
/s/ James E Burns | 02/15/2018 | |
** 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 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. |