Statement of Changes in Beneficial Ownership (4)
December 16 2016 - 11:24AM
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
*
Sample Steven L
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2. Issuer Name
and
Ticker or Trading Symbol
Acacia Diversified Holdings, Inc.
[
ACCA
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__
X
__ Director
__
X
__ 10% Owner
_____ Officer (give title below)
_____ Other (specify below)
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(Last)
(First)
(Middle)
3512 E. SILVER SPRINGS BLVD - #243
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3. Date of Earliest Transaction
(MM/DD/YYYY)
10/3/2016
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(Street)
OCALA, FL 34470
(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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Common stock
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11/11/2016
(1)
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G
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1491058
(1)
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D
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$0
(2)
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4029721
(3)
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D
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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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Explanation of Responses:
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(
1)
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Transactions included 491,058 shares gifted on 10/31/2016 and 1,000,000 shares gifted on 11/11/2016 for a total of 1,491,058 shares.
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(
2)
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Shares gifted to others by the Reporting Person
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(
3)
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Following these gifting transactions, Reporting Person owned 4,029,721 shares of the Common stock of Issuer. 2,500,000 of those shares are currently held in trust by another person who holds a Proxy from Reporting Person to vote those shares and the Right of First Refusal to purchase those Common shares between April 4th and May 4th of 2019, but who does not currently have beneficial ownership of those shares.
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Remarks:
Reporting Person is reporting an ownership interest of 10% or more of the issued and outstanding Common shares of Issuer. However; Following these gifting transactions, Reporting Person owned 4,029,721 shares of the Common stock of Issuer. 2,500,000 of those shares are currently held in trust by another person who holds a Proxy from Reporting Person to vote those shares and the Right of First Refusal to purchase those Common shares between April 4th and May 4th of 2019, but who does not currently have beneficial ownership of those shares. As such, Reporting Person does not hold the influence of 10% or more of the Issuer's outstanding shares.
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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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Sample Steven L
3512 E. SILVER SPRINGS BLVD - #243
OCALA, FL 34470
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X
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X
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Signatures
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/s/ Steven L. Sample
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12/16/2016
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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 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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