Amended Statement of Changes in Beneficial Ownership (4/a)
15 Fevereiro 2018 - 8:08PM
Edgar (US Regulatory)
FORM 4
[ ]
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b).
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0287
Estimated average burden
hours per response...
0.5
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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
*
Burns James Edward
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2. Issuer Name
and
Ticker or Trading Symbol
Petrolia Energy Corp
[
BBLS
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__
X
__ Director
_____ 10% Owner
__
X
__ Officer (give title below)
_____ Other (specify below)
President
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(Last)
(First)
(Middle)
3322 DESERT INN
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3. Date of Earliest Transaction
(MM/DD/YYYY)
4/18/2017
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(Street)
MONTGOMERY, TX 77356
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
6/15/2017
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6. Individual or Joint/Group Filing
(Check Applicable Line)
_
X
_ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person
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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)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code
(Instr. 8)
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4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)
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7. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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Amount
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(A) or (D)
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Price
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Common Stock
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1550000
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D
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Table II - Derivative Securities Beneficially Owned (
e.g.
, puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 3)
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2. Conversion or Exercise Price of Derivative Security
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3. Trans. Date
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3A. Deemed Execution Date, if any
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4. Trans. Code
(Instr. 8)
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5. Number of Derivative Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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6. Date Exercisable and Expiration Date
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7. Title and Amount of Securities Underlying Derivative Security
(Instr. 3 and 4)
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8. Price of Derivative Security
(Instr. 5)
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9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4)
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10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4)
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11. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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(A)
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(D)
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Date Exercisable
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Expiration Date
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Title
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Amount or Number of Shares
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Series A Convertible Preferred Stock
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$0.14
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5/26/2017
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A
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10500
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5/26/2017
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(1)
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Common Stock
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750000
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$10
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10500
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D
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Series A Convertible Preferred Stock
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$0.14
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5/23/2017
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A
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3000
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5/23/2017
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(1)
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Common Stock
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214286
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$10
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13500
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D
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Series A Convertible Preferred Stock
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$0.14
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4/18/2017
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A
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2900
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4/18/2017
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(1)
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Common Stock
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207143
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$10
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16400
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D
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Explanation of Responses:
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(1)
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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.
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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.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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Burns James Edward
3322 DESERT INN
MONTGOMERY, TX 77356
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X
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President
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Signatures
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/s/ James E Burns
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2/15/2018
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 4(b)(v).
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**
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Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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Note:
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File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure.
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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.
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