|
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940 |
|
| |||||||||||||||||||||||||||||
|
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | |||
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 control number. | SEC 1474 (9-02) |
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 Underlying Securities (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 of Derivative Security: 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 | ||||||||
Common Stock Purchase Warrant | $ 5.28 | 11/18/2016 | X | 47,604 | 11/09/2015 | 11/09/2020 | Common Stock, Par Value | 47,604 (2) | $ 5.28 | 237,467 | I | See Footnote (3) | |||
Stock Options (4) | $ 7.21 | 08/16/2016 | 08/16/2021 | Common Stock, Par Value $0.001 | $ 10,000 (4) | $ 10,000 (4) | D | ||||||||
Stock Options (1) | $ 7.01 | 12/17/2015(1) | 12/17/2020 | Common Stock, Par Value $0.001 | 50,000 (1) | 50,000 (1) | D | ||||||||
Common Stock Purchase Warrant | $ 5.28 | 12/04/2015 | 12/04/2020 | Common Stock, Par Value $0.001 | 142,857 (2) | 142,857 | I | See Footnote (3) |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Samuels H. Benjamin C/O WORKHORSE GROUP INC. 100 COMMERCE DRIVE LOVELAND, OH 45140 |
X |
/s/ H. Benjamin Samuels | 11/18/2016 | |
**Signature of Reporting Person | Date |
* | 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). |
(1) | 10,000 of the options vested on December 17, 2015 and 4,000 shall vest every six (6) months thereafter on June 30 and December 31. |
(2) | On November 9, 2015, Samuels 2012 Children's Trust UAD 10/28/12 (the "Trust") acquired a Stock Purchase Warrant to acquire 428,571 shares of common stock (the "Initial Warrant"). On December 4, 2015, the Trust acquired a Stock Purchase Warrant to acquire 142,857 shares of common stock. On January 5, 2016, convertible notes held by the Trust were automatically converted into 571,429 shares of common stock. Further, on September 14, 2016, the Trust exercised the Initial Warrant and received 143,500 shares of common stock for a purchase price of $757,680 or $5.28 per share and on November 18, 2016, the Trust exercised the Initial Warrant and received 47,604 shares of common stock for a purchase price of $251,349 or $5.28 per share |
(3) | H. Benjamin Samuels is a trustee and beneficiary of the Trust |
(4) | 2,500 of the options vested on August 16, 2016 and an additional 2,500 will vest every six months thereafter. |