Annual Statement of Changes in Beneficial Ownership (5)
14 Agosto 2013 - 3:35PM
Edgar (US Regulatory)
FORM 5
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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).
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Form 3 Holdings Reported
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X
]
Form 4 Transactions Reported
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0362
Estimated average burden
hours per response...
1.0
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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
*
FALLAT DALE W
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2. Issuer Name
and
Ticker or Trading Symbol
GREENSHIFT CORP [GERS]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
_____ Director
__
X
__ 10% Owner
_____ Officer (give title below)
_____ Other (specify below)
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(Last)
(First)
(Middle)
6704 REGENTS PARK DRIVE
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3. Statement for Issuer's Fiscal Year Ended
(MM/DD/YYYY)
12/31/2012
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(Street)
ZIONSVILLE, IN 46077
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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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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Amount
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(A) or (D)
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Price
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Common Stock
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12/20/2012
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P4
(1)
(2)
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151363
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A
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$0.0268
(3)
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8104349
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D
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Common Stock
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12/21/2012
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P4
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31009
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A
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$0.0265
(4)
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8135358
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D
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Common Stock
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12/24/2012
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P4
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65540
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A
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$0.0260
(5)
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8200898
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D
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Common Stock
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12/26/2012
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P4
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122020
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A
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$0.0278
(6)
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8322918
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D
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Common Stock
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12/27/2012
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P4
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206938
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A
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$0.0280
(7)
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8529856
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D
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Common Stock
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12/28/2012
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P4
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2058872
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A
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$0.0257
(8)
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10588728
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D
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Common Stock
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12/31/2012
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P4
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542000
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A
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$0.0316
(9)
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11130728
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D
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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 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
(MM/DD/YYYY)
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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 at End of Issuer's Fiscal Year
(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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(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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Explanation of Responses:
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(
1)
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The reporting person purchased 50,075 shares of Greenshift Corporation common stock on 11/14/2012 and, as a result, became a greater than 10% owner of Greenshift Corporation common stock.
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(
2)
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The sales of common stock by Mr. Fallat were matchable under Section 16(b) of the Securities Exchange Act of 1934 ("Section 16(b)") with the purchases by Mr. Fallat of 2,312,383 shares of common stock from November 14, 2012 through February 11, 2013. Mr. Fallat paid $16,008.17 to the Company in accordance with Section 16(b), representing deemed profit from the sales matchable with such purchases, calculated pursuant to Section 16(b). These matchable transactions are reported on several Forms 4 and Forms 5 filed today.
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(
3)
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The price reported in column 4 is a weighted average price. These shares were purchased in multiple transactions at prices ranging from $0.0200 to $0.0280, inclusive. The reporting person undertakes to provide Greenshift Corporation, any security holder of Greenshift Corporation, or the staff of the Securities and Exchange Commmission, upon request, full information regarding the number of shares purchased at each separate price within the range set forth in this footnote.
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(
4)
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The price reported in column 4 is a weighted average price. These shares were purchased in multiple transactions at prices ranging from $0.0244 to $0.0280, inclusive. The reporting person undertakes to provide Greenshift Corporation, any security holder of Greenshift Corporation, or the staff of the Securities and Exchange Commmission, upon request, full information regarding the number of shares purchased at each separate price within the range set forth in this footnote.
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(
5)
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The price reported in column 4 is a weighted average price. These shares were purchased in multiple transactions at prices ranging from $0.0255 to $0.0280, inclusive. The reporting person undertakes to provide Greenshift Corporation, any security holder of Greenshift Corporation, or the staff of the Securities and Exchange Commmission, upon request, full information regarding the number of shares purchased at each separate price within the range set forth in this footnote.
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(
6)
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The price reported in column 4 is a weighted average price. These shares were purchased in multiple transactions at prices ranging from $0.0260 to $0.0290, inclusive. The reporting person undertakes to provide Greenshift Corporation, any security holder of Greenshift Corporation, or the staff of the Securities and Exchange Commmission, upon request, full information regarding the number of shares purchased at each separate price within the range set forth in this footnote.
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(
7)
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The price reported in column 4 is a weighted average price. These shares were purchased in multiple transactions at prices ranging from $0.0260 to $0.0290, inclusive. The reporting person undertakes to provide Greenshift Corporation, any security holder of Greenshift Corporation, or the staff of the Securities and Exchange Commmission, upon request, full information regarding the number of shares purchased at each separate price within the range set forth in this footnote.
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(
8)
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The price reported in column 4 is a weighted average price. These shares were purchased in multiple transactions at prices ranging from $0.0221 to $0.0285, inclusive. The reporting person undertakes to provide Greenshift Corporation, any security holder of Greenshift Corporation, or the staff of the Securities and Exchange Commmission, upon request, full information regarding the number of shares purchased at each separate price within the range set forth in this footnote.
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(
9)
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The price reported in column 4 is a weighted average price. These shares were purchased in multiple transactions at prices ranging from $0.0270 to $0.0340, inclusive. The reporting person undertakes to provide Greenshift Corporation, any security holder of Greenshift Corporation, or the staff of the Securities and Exchange Commmission, upon request, full information regarding the number of shares purchased at each separate price within the range set forth in this footnote.
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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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FALLAT DALE W
6704 REGENTS PARK DRIVE
ZIONSVILLE, IN 46077
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X
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Signatures
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/s/ Dale W. Fallat
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8/14/2013
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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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