Statement of Changes in Beneficial Ownership (4)
June 07 2018 - 4:49PM
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
*
Estate of Landon Thomas Clay
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2. Issuer Name
and
Ticker or Trading Symbol
GOLDEN QUEEN MINING CO LTD
[
GQM
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
_____ Director
__
X
__ 10% Owner
_____ Officer (give title below)
_____ Other (specify below)
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(Last)
(First)
(Middle)
C/O EAST HILL MANAGEMENT COMPANY, LLC, 70 MAIN STREET, SUITE 300
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3. Date of Earliest Transaction
(MM/DD/YYYY)
5/15/2018
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(Street)
PETERBOROUGH, NH 03458
(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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5/15/2018
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W
(1)
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V
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4663
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D
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$0
(1)
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118415009
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D
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Common Stock
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6/5/2018
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J
(2)
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248082
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A
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$0
(2)
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118663091
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D
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Common Stock
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6/5/2018
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J
(2)
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248082
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D
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$0
(2)
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0
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I
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By corporation
(2)
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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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Represents shares of common stock of Golden Queen Mining Co. Ltd. (the "Issuer") that were held in an individual retirement account in the name of Mr. Landon Thomas Clay (the "IRA"). Ownership of these shares of common stock passed to Mr. Landon Thomas Clay's spouse following the death of Mr. Landon Thomas Clay in July 2017.
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(2)
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Represents shares of common stock of the Issuer held by LTC Corporation ("LTC Corp"). The Reporting Person is the sole stockholder of LTC Corp following the death of Mr. Landon Thomas Clay in July 2017. On June 5, 2018, LTC Corp distributed all of its shares of common stock of the Issuer to the Reporting Person. Following this distribution the Reporting Person will report these shares of common stock of the Issuer as being directly beneficially owned.
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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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Estate of Landon Thomas Clay
C/O EAST HILL MANAGEMENT COMPANY, LLC
70 MAIN STREET, SUITE 300
PETERBOROUGH, NH 03458
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X
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Signatures
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/s/ Thomas M. Clay, Executor
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6/7/2018
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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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