Initial Statement of Beneficial Ownership (3)
October 03 2016 - 4:29PM
Edgar (US Regulatory)
FORM 3
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0104
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
*
McGregor James R.
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2. Date of Event Requiring Statement (MM/DD/YYYY)
9/20/2016
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3. Issuer Name
and
Ticker or Trading Symbol
Jayhawk Energy, Inc. [JYHW]
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(Last)
(First)
(Middle)
269 E. 1210 S.
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4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director
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X
___ 10% Owner
_____ Officer (give title below)
_____ Other (specify below)
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(Street)
LEHI, UT 84043
(City)
(State)
(Zip)
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5. 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 Beneficially Owned
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1.Title of Security
(Instr. 4)
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2. Amount of Securities Beneficially Owned
(Instr. 4)
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3. Ownership Form: Direct (D) or Indirect (I)
(Instr. 5)
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4. Nature of Indirect Beneficial Ownership
(Instr. 5)
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Common stock
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39624719
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I
(1)
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By JEM Equity, LLC
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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. 4)
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2. Date Exercisable and Expiration Date
(MM/DD/YYYY)
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3. Title and Amount of Securities Underlying Derivative Security
(Instr. 4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
(Instr. 5)
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6. Nature of Indirect Beneficial Ownership
(Instr. 5)
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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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Convertible Promissory Note
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9/20/2016
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9/19/2018
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Common stock
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1000000
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$0.0065
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I
(1)
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By GEM Equity, LLC
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Stock Purchase Warrant
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10/8/2015
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10/7/2020
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Common stock
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23583418
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$0.005
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I
(1)
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By GEM Equity, LLC
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Explanation of Responses:
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(
1)
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Mr. James McGregor is the Managing Member of JEM Equity, LLC, and therefore is deemed to be a Beneficial Owner of JEM Equity, LLC's ownership interests in JayHawk Energy, Inc. by virtue of the voting and dispositive control Mr. McGregor has over JEM Equity, LLC. Mr. McGregor disclaims any Beneficial Ownership in the JayHawk Energy, Inc. interests.
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Remarks:
No securities are beneficially owned by the Person signing on
behalf of the Reporting Person
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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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McGregor James R.
269 E. 1210 S.
LEHI, UT 84043
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X
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Signatures
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/s/ James R. McGregor
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9/23/2016
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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 5(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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