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) 01/25/2018 | 3. Issuer Name and Ticker or Trading Symbol GOLDEN QUEEN MINING CO LTD [ GQM ] | |||||||||||||
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 | 17,052,402 | D | |
Common Stock | 26,114 | I | By corporation(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 | ||||
Subscription Rights (right to acquire)(2) | 01/11/2018 | 02/20/2018 | Common Stock | 17,052,402(3) | 0.1325 | D | |
Subscription Rights (right to acquire)(2) | 01/11/2018 | 02/20/2018 | Common Stock | 26,114(4) | 0.1325 | I | By corporation(1) |
Explanation of Responses: |
1. Represents shares held by LTC Corporation ("LTC Corp"). The reporting person owns all of the equity interests of LTC Corp. The equity interests of LTC Corp transferred automatically to the reporting person following the death of Landon T. Clay in July 2017. |
2. Golden Queen Mining Company, LLC (the "Issuer") commenced a pro-rata rights offering (the "Offering") on December 1, 2017. Pursuant to the terms of the Offering, each stockholder of the Issuer received one transferable right (each a "Right") for each share of common stock of the Issuer owned by such stockholder. Each Right entitles the holder thereof to purchase 1.7 shares of common stock of the Issuer at an exercise price of US$0.1325 per share of common stock. The Rights are exercisable until February 20, 2018. |
3. Represents Rights received directly from the Issuer, as well as rights received by the reporting person in a distribution as the beneficiary of the Landon T. Clay 2016-2 Annuity Trust u/a dated January 14, 2016. |
4. Represents Rights received directly from the Issuer. |
/s/ Thomas M. Clay, Executor | 01/29/2018 | |
** 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. |