UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549INITIAL STATEMENT OF 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 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | SEC 1473 (7-02) | ||
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. |
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 of Derivative Security: Direct (D) or Indirect (I) (Instr. 5) |
6. Nature of Indirect Beneficial Ownership (Instr. 5) |
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Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Warrant | 07/13/2012 | 07/13/2017 | Common Stock | 3,750,000 | $ 0.01 | I | Owns 100% of record holder - corporation |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Groussman Mark 4721 IRONTON STREET, BUILDING A DENVER, CO 80239 |
 X |  |  |  |
/s/ Mark Groussman | 07/24/2012 | |
**Signature of Reporting Person | Date |
* | 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). |
(1) | In addition, pursuant to a consulting agreement with the Issuer, the Reporting Person has the right to receive additional shares of common stock equal to 4.2% of the Company on a fully diluted (as-converted) basis. The shares are to be issued upon the Issuer's completion of a contemplated reverse stock split. As the amount of shares to be issued is indeterminate at this time, the Reporting Person intends to report the issuance on Form 4 within two business days of issuance. |