Statement of Changes in Beneficial Ownership (4)
October 23 2017 - 5:17PM
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
*
COVELY FRED
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2. Issuer Name
and
Ticker or Trading Symbol
GREY CLOAK TECH INC.
[
GRCK
]
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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)
CEO
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(Last)
(First)
(Middle)
10300 W CHARLESTON BLVD.
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3. Date of Earliest Transaction
(MM/DD/YYYY)
10/17/2017
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(Street)
LAS VEGAS, NV 89135
(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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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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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 Covertible Preferred Stock
(1)
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$0.00
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10/17/2017
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A
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41403
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10/17/2017
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(3)
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Common Stock
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6555322
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$0.00
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41403
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D
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Convertible Promissory Note
(2)
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(2)
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10/17/2017
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P
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$30000
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10/17/2017
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10/17/2018
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Common Stock
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4285715
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$30000
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$30000
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D
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Warrrants
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$0.25
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10/17/2017
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P
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1200000
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10/17/2017
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10/17/2020
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Common Stock
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1200000
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$0.00
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1200000
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D
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Explanation of Responses:
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(1)
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Each share of the Series A Convertible Preferred Stock is convertible into the number of shares equal to 0.00006% of the Company's outstanding common stock immediately after conversion. As of October 20, 2017, the reporting person's Series A Convertible Preferred Stock was convertible into 6,555,322 shares of common stock.
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(2)
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The Note has a $30,000 principal amount, bears interest at a rate of five percent per annum, and is convertible into shares of common stock at a conversion price equal to fifty percent (50%) of the average of the closing trading price for the Company's common stock during the three trading day period ending on the last trading day prior to the conversion date. As of October 20, 2017, that three day average was $0.014 per share, and the conversion price (50%) was $0.007 per share, for a total of 4,285,715 shares of common stock.
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(3)
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Security does not expire.
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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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COVELY FRED
10300 W CHARLESTON BLVD.
LAS VEGAS, NV 89135
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X
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X
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CEO
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Signatures
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/s/ Fred Covely
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10/23/2017
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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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