Initial Statement of Beneficial Ownership (3)
July 29 2020 - 5:40PM
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
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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
*
Bearden Jeffery Dwight |
2. Date of Event Requiring Statement (MM/DD/YYYY)
6/12/2020
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3. Issuer Name and Ticker or Trading Symbol
Acacia Diversified Holdings, Inc. [ACCA]
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(Last)
(First)
(Middle)
704 FOREST GLEN ROAD |
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
__X__ Director _____ 10% Owner ___X___ Officer (give title below) _____ Other (specify below) Chief Executive Officer / |
(Street)
SILVER SPRING, MD 20901
(City)
(State)
(Zip)
| 5. If Amendment, Date Original Filed(MM/DD/YYYY)
| 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) | 2. Amount of Securities Beneficially Owned (Instr. 4) | 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 4. Nature of Indirect Beneficial Ownership (Instr. 5) |
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) | 2. Date Exercisable and Expiration Date (MM/DD/YYYY) | 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) |
Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Series B Convertible Preferred Stock | (1) | (2) | Common Stock (3) | 73750000 | $0 | I (4) | Through ownership of ORCIM Financial Holdings, LLC |
Explanation of Responses: |
(1) | There is no exercise date for the Series B Convertible Preferred Stock, as it is convertible at the discretion of the reporting person's limited liability company. |
(2) | There is no expiration date for the Series B Convertible Preferred Stock. |
(3) | Each share of Series B Convertible Preferred Stock is convertible into 50 shares of the issuer's Common Stock. |
(4) | The 1,475,000 shares of Series B Convertible Preferred Stock is owned by ORCIM Financial Holdings, LLC, a Maryland limited liability company that is wholly-owned by the reporting person. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Bearden Jeffery Dwight 704 FOREST GLEN ROAD SILVER SPRING, MD 20901 | X |
| Chief Executive Officer |
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Signatures
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Jeffery D. Bearden | | 7/29/2020 |
**Signature of Reporting Person | Date |
by Clifford J. Hunt, Esquire, PoA | | 7/29/2020 |
**Signature of Reporting Person | Date |
Acacia Diversified (CE) (USOTC:ACCA)
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