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) 06/27/2016 | 3. Issuer Name and Ticker or Trading Symbol IMAGE SENSING SYSTEMS INC [ ISNS ] | |||||||||||||
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) |
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 | ||||
Employee Stock Option (right to buy) | (1) | 08/09/2017 | Common Stock | 4,000 | 8 | D | |
Employee Stock Option (right to buy) | (2) | 09/17/2022 | Common Stock | 3,000 | 5 | D | |
Employee Stock Option (right to buy) | (3) | 08/20/2023 | Common Stock | 2,000 | 7.1 | D | |
Employee Stock Option (right to buy) | (4) | 05/13/2024 | Common Stock | 4,000 | 4.22 | D |
Explanation of Responses: |
1. The option became exercisable in four equal installments on August 9, 2012, August 9, 2013, August 9, 2014 and August 9, 2015. |
2. The option is exercisable in four equal installments. The first three installments became exercisable on September 17, 2013, September 17, 2014 and September 17, 2015, and the last installment will become exercisable on September 17, 2016. |
3. The option is exercisable in four equal installments. The first two installments became exercisable on August 20, 2014 and August 20, 2015, and the next two installments will become exercisable on August 20, 2016 and August 20, 2017. |
4. The option is exercisable in four equal installments. The first two installments became exercisable on May 13, 2015 and May 13, 2016, and the next two installments will become exercisable on May 13, 2017 and May 13, 2018. |
/s/ Chad Stelzig | 06/29/2016 | |
** 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 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. |