Statement of Changes in Beneficial Ownership (4)
November 07 2018 - 3:54PM
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
*
SIEM IVAR
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2. Issuer Name
and
Ticker or Trading Symbol
Petrolia Energy Corp
[
BBLS
]
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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)
710 N. POST OAK RD., STE. 512
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3. Date of Earliest Transaction
(MM/DD/YYYY)
7/24/2018
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(Street)
HOUSTON, TX 77024
(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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7/24/2018
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P
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468750
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A
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$0.065
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1885416
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I
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American Resources Offshore Inc.
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Common Stock
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8/15/2018
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P
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547755
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A
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$0.064
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2433171
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I
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American Resources Offshore Inc.
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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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Warrants to Purchase Common Stock
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$0.10
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8/17/2018
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A
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20000
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8/17/2018
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8/17/2019
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Common Stock
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20000
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(1)
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20000
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I
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American Resources Offshore Inc.
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Convertible Promissory Note
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$0.10
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8/17/2018
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A
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$20000
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8/17/2018
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10/17/2018
(2)
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Common Stock
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200000
(3)
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$20000
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$20000
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I
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American Resources Offshore Inc.
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Options to Purchase Common Stock
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$0.10
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9/30/2018
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A
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250000
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9/30/2018
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9/30/2020
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Common Stock
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250000
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(4)
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250000
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D
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Explanation of Responses:
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(1)
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As additional consideration for entering into the Convertible Promissory Note on the same date (as described in the table above), the Issuer granted the Reporting Person one-year warrants to purchase one share of the Issuer's common stock at an exercise price of $0.10 per share for each dollar loaned pursuant to the Convertible Promissory Note. Exempt pursuant to Rule 16b3(d).
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(2)
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The Convertible Promissory Note was due on October 17, 2018.
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(3)
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Not including any shares issuable upon conversion of accrued interest. The Convertible Promissory Note accrues interest at the rate of 12% per annum until paid in full, which interest is convertible into shares of common stock on the same terms as the principal amount of the debt. Exempt pursuant to Rule 16b3(d).
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(4)
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Issued in consideration for services rendered. Exempt pursuant to Rule 16b3(d).
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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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SIEM IVAR
710 N. POST OAK RD., STE. 512
HOUSTON, TX 77024
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X
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Signatures
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/s/ Ivar Siem
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11/7/2018
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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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