- Amended Statement of Changes in Beneficial Ownership (4/A)
April 17 2012 - 9:01PM
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, Section 17(a) of the Public
Utility Holding Company Act of 1935 or Section 30(f) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person
*
COLBY Bradley
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2. Issuer Name
and
Ticker or Trading Symbol
AMERICAN EAGLE ENERGY Corp
[
AMZG
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__
X
__ Director
_____ 10% Owner
__
X
__ Officer (give title below)
_____ Other (specify below)
CEO/PRESIDENT
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(Last)
(First)
(Middle)
5722 S. BENTON WAY
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3. Date of Earliest Transaction
(MM/DD/YYYY)
12/20/2011
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(Street)
LITTLETON, CO 80123
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
12/21/2011
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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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555556
(1)
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D
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Common Stock
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33334
(2)
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I
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Spouse
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Common Stock
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33334
(3)
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I
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Adult Child
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Common Stock
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33334
(3)
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I
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Adult Child
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Common Stock
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33334
(3)
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I
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Adult Child
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Common Stock
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33334
(4)
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I
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Child
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Common Stock
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12/20/2011
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J
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1817648
(5)
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A
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(5)
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2373204
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D
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Common Stock
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12/20/2011
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J
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56638
(6)
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A
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(6)
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89972
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I
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Spouse
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Common Stock
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12/20/2011
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J
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56638
(7)
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A
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(7)
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89972
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I
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Adult Child
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Common Stock
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12/20/2011
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J
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56638
(7)
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A
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(7)
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89972
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I
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Adult Child
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Common Stock
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12/20/2011
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J
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56638
(7)
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A
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(7)
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89972
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I
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Adult Child
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Common Stock
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12/20/2011
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J
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56638
(8)
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A
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(8)
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89972
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I
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Child
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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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Common Stock Purchase Option
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$0.225
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10/30/2009
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J
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0
(9)
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10/30/2009
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10/29/2014
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Common Stock
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512778
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$0.225
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512778
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D
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Common Stock Purchase Option
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$0.74
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12/30/2010
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J
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0
(9)
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12/30/2010
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12/30/2015
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Common Stock
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144416
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$0.74
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657194
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D
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Explanation of Responses:
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(
1)
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Reflects amount of securities beneficially owned after taking into account adjustments for the merger between American Eagle Energy Inc. and Eternal Energy Corp. (now known as American Eagle Energy Corporation) and subsequent reverse split.
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(
2)
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Reflects amount of securities owned after taking into account all post-transaction, post-reverse split adjustments. These shares are held by the reporting person's wife. The reporting person disclaims beneficial ownership of such securities, and this report should not be deemed an admission that the reporting person is the beneficial owner of such securities for purposes of Section 16 or for any other purpose.
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(
3)
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Reflects amount of securities owned after taking into account all post-transaction, post-reverse split adjustments. These shares are held by the reporting person's adult child. The reporting person disclaims beneficial ownership of such securities, and this report should not be deemed an admission that the reporting person is the beneficial owner of such securities for purposes of Section 16 or for any other purpose.
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(
4)
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Reflects amount of securities owned after taking into account all post-transaction, post-reverse split adjustments. These shares are held by the reporting person's child.
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(
5)
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Reflects shares acquired in reported transaction and subsequent reverse split after taking into account all post-transaction, post-reverse split adjustments.
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(
6)
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Reflects shares acquired in reported transaction and subsequent reverse split after taking into account all post-transaction, post-reverse split adjustments. These shares are held by the reporting person's wife. The reporting person disclaims beneficial ownership of such securities, and this report should not be deemed an admission that the reporting person is the beneficial owner of such securities for purposes of Section 16 or for any other purpose.
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(
7)
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Reflects shares acquired in reported transaction and subsequent reverse split after taking into account all post-transaction, post-reverse split adjustments. These shares are held by the reporting person's adult child. The reporting person disclaims beneficial ownership of such securities, and this report should not be deemed an admission that the reporting person is the beneficial owner of such securities for purposes of Section 16 or for any other purpose.
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(
8)
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Reflects shares acquired in reported transaction and subsequent reverse split after taking into account all post-transaction, post-reverse split adjustments. These shares are held by the reporting person's child.
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(
9)
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No new options acquired. Reflects amount of options held following the merger between American Eagle Energy Inc. and Eternal Energy Corp (now known as American Eagle Energy Corporation) after taking into account all post-transaction, post-reverse split adjustments.
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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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COLBY Bradley
5722 S. BENTON WAY
LITTLETON, CO 80123
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X
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CEO/PRESIDENT
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Signatures
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/s/ Bradley Colby
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4/17/2012
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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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