- Annual Statement of Changes in Beneficial Ownership (5)
07 Abril 2011 - 9:49PM
Edgar (US Regulatory)
FORM 5
[ ]
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b).
[
X
]
Form 3 Holdings Reported
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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
Expires:
February 28, 2011
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, Section 17(a) of the Public
Utility Holding Company Act of 1935 or Section 30(f) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person
*
Olmstead Scott
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2. Issuer Name
and
Ticker or Trading Symbol
Paneltech International Holdings, Inc. [PNLT]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__
X
__ Director
__
X
__ 10% Owner
__
X
__ Officer (give title below)
_____ Other (specify below)
CFO, Secretary and Director
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(Last)
(First)
(Middle)
2999 JOHN STEVENS WAY
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3. Statement for Issuer's Fiscal Year Ended
(MM/DD/YYYY)
12/31/2010
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(Street)
HOQUIAM, WA 98550
(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)
___ Form Filed by One Reporting Person
_
X
_ 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, par value $0.0001
(2)
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3
(1)
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6178624
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I
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By SORB Management Corporation
(2)
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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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This transaction reflects holdings reportable on Form 3 on April 20, 2010, the date of the effectiveness of the registration of the Issuer's common stock pursuant to Section 12(g) of the Exchange Act.
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(
2)
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This Form 5 is filed jointly by Scott Olmstead and SORB Management Corporation. Mr. Olmstead is deemed to be a 10% owner of the Issuer and SORB Management Corporation is a 10% owner of the Issuer. The securities reported in this Form 5 are owned directly by SORB Management Corporation and owned indirectly by Mr. Olmstead by virtue of his position as President of SORB Management Corporation. Mr. Olmstead holds all of the outstanding shares of common stock of SORB Management Corporation as community property with his wife.
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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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Olmstead Scott
2999 JOHN STEVENS WAY
HOQUIAM, WA 98550
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X
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X
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CFO, Secretary and Director
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SORB Management Corp
3873 WISHKAH ROAD
ABERDEEN, WA 98520
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X
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Signatures
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/s/ Scott Olmstead
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4/7/2011
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**
Signature of Reporting Person
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Date
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/s/ Scott Olmstead, President, on behalf of SORB Management Corporation
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4/7/2011
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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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