Statement of Changes in Beneficial Ownership (4)
September 12 2018 - 6:09PM
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
*
Hayes John William
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2. Issuer Name
and
Ticker or Trading Symbol
BlackRidge Technology International, Inc.
[
BRTI
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__
X
__ Director
_____ 10% Owner
_____ Officer (give title below)
_____ Other (specify below)
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(Last)
(First)
(Middle)
10615 PROFESSIONAL CIRCLE, SUITE 201
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3. Date of Earliest Transaction
(MM/DD/YYYY)
11/9/2017
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(Street)
RENO, NV 89521
(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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11/9/2017
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C
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10757254
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A
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$0
(1)
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17751611
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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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Common Stock Covertible
(1)
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$0.5
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11/9/2017
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C
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10757254
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(1)
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11/9/2017
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Common Stock
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10757254
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(1)
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0
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D
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Warrant to Purchase Common Stock
(1)
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$0.5
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11/9/2017
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P
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1344656
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11/9/2017
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11/9/2019
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Common Stock
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1344656
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(1)
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1344656
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D
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Warrant to Purchase Common Stock
(1)
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$0.5
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11/9/2017
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P
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1344657
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11/9/2017
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11/9/2020
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Common Stock
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1344657
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(1)
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1344656
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D
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Warrant to Purchase Common Stock
(1)
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$0.5
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11/9/2017
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P
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1344657
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11/9/2017
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11/9/2021
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Common Stock
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1344657
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(1)
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1344656
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D
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Warrant to Purchase Common Stock
(1)
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$0.5
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11/9/2017
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P
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1344657
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11/9/2017
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11/9/2022
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Common Stock
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1344657
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(1)
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1344656
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D
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Warrant to Purchase Common Stock
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$0.25
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7/6/2018
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P
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800000
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7/6/2018
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7/6/2023
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Common Stock
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800000
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(2)
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7367285
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D
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Explanation of Responses:
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(1)
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From 2011 to 2014, Mr. Hayes loaned a total of $2,673,200 to the issuer. On October 1, 2014, all prior notes including accrued interest were combined into a single $3,712,637 convertible note bearing interest at 12% annually and convertible into 4,125,154 shares of preferred stock at the rate of $0.90 per share. On November 9, 2017, the issuer converted the note and accrued interest of $1,665,991 into 10,757,254 shares of the issuer's common stock at a conversion rate of $0.50 per share. The issuer also issued a 5 year warrant to purchase an additional 5,378,627 shares of the issuer's common stock at a purchase price of $0.50 per share as further consideration for this conversion.
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(2)
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On July 10, 2018, Mr. Hayes purchased a convertible note in the principal amount of $200,000 and warrants to purchase 800,000 shares of the issuer's common stock for an aggregate amount of $200,000. The note is convertible into the issuer's Series B Preferred Stock.
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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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Hayes John William
10615 PROFESSIONAL CIRCLE, SUITE 201
RENO, NV 89521
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X
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Signatures
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/s/John Hayes
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9/12/2018
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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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