Annual Statement of Changes in Beneficial Ownership (5)
August 18 2017 - 5:17PM
Edgar (US Regulatory)
FORM 5
[ ]
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b).
[ ]
Form 3 Holdings Reported
[ ]
Form 4 Transactions Reported
|
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
|
OMB APPROVAL
OMB Number:
3235-0362
Estimated average burden
hours per response...
1.0
|
|
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940
|
|
1. Name and Address of Reporting Person
*
WARD MICHAEL R
|
2. Issuer Name
and
Ticker or Trading Symbol
Mirage Energy Corp [MRGE]
|
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__
X
__ Director
__
X
__ 10% Owner
__
X
__ Officer (give title below)
_____ Other (specify below)
CEO
|
(Last)
(First)
(Middle)
900 ISON ST., STE. 306
|
3. Statement for Issuer's Fiscal Year Ended
(MM/DD/YYYY)
7/31/2017
|
(Street)
SAN ANTONIO, TX 78216
(City)
(State)
(Zip)
|
4. If Amendment, Date Original Filed
(MM/DD/YYYY)
|
6. Individual or Joint/Group Filing
(Check Applicable Line)
_
X
_ Form Filed by One Reporting Person
___ Form Filed by More than One Reporting Person
|
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
|
1.Title of Security
(Instr. 3)
|
2. Trans. Date
|
2A. Deemed Execution Date, if any
|
3. Trans. Code
(Instr. 8)
|
4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
|
5. Amount of Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 3 and 4)
|
6. Ownership Form: Direct (D) or Indirect (I)
(Instr. 4)
|
7. Nature of Indirect Beneficial Ownership
(Instr. 4)
|
Amount
|
(A) or (D)
|
Price
|
Common Stock
(1)
|
8/11/2016
|
|
P
|
117864000
|
D
|
$150604
|
127864000
(2)
|
D
|
|
Common Stock
(3)
|
1/24/2017
|
|
P
|
10000000
|
D
|
$0
(5)
|
10000000
|
D
|
|
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (
e.g.
, puts, calls, warrants, options, convertible securities)
|
1. Title of Derivate Security
(Instr. 3)
|
2. Conversion or Exercise Price of Derivative Security
|
3. Trans. Date
|
3A. Deemed Execution Date, if any
|
4. Trans. Code
(Instr. 8)
|
5. Number of Derivative Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
|
6. Date Exercisable and Expiration Date
(MM/DD/YYYY)
|
7. Title and Amount of Securities Underlying Derivative Security
(Instr. 3 and 4)
|
8. Price of Derivative Security
(Instr. 5)
|
9. Number of Derivative Securities Beneficially Owned at End of Issuer's Fiscal Year
(Instr. 4)
|
10. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
(Instr. 4)
|
11. Nature of Indirect Beneficial Ownership
(Instr. 4)
|
(A)
|
(D)
|
Date Exercisable
|
Expiration Date
|
Title
|
Amount or Number of Shares
|
Preferred Stock Series A
(4)
|
$0
(5)
|
1/24/2017
|
|
P
|
10000000
|
|
1/24/2017
|
(7)
|
Common
|
200000000
|
$0
(5)
|
10000000
(6)
|
D
|
|
Explanation of Responses:
|
(1)
|
Previously reported Form 3 on 8/16/16 as 3,274,000 pre-forward split shares.
|
(2)
|
The 127,864,000 includes the 10,000,000 shares from Line 2.
|
(3)
|
Shares acquired in a business combination transaction as disclosed on Form 8-K filed 1/27/17.
|
(4)
|
The Series A shares were acquired in a business combination transaction described in Current Report Form 8-K filed January 27, 2017.
The Series A Preferred Stock was designated in an amendment to the Company's articles of Incorporation filed in Current Report on Form 8-K on November 10, 2016.
|
(5)
|
No monetary value established in a share exchange business combination transaction.
|
(6)
|
Series A
|
(7)
|
N/A
|
Reporting Owners
|
Reporting Owner Name / Address
|
Relationships
|
Director
|
10% Owner
|
Officer
|
Other
|
WARD MICHAEL R
900 ISON ST., STE. 306
SAN ANTONIO, TX 78216
|
X
|
X
|
CEO
|
|
Signatures
|
/s/ Michael Ward
|
|
8/11/2017
|
**
Signature of Reporting Person
|
Date
|
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
|
*
|
If the form is filed by more than one reporting person,
see
Instruction 4(b)(v).
|
**
|
Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
|
Note:
|
File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure.
|
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.
|
Mirage Energy (PK) (USOTC:MRGE)
Historical Stock Chart
From Oct 2024 to Nov 2024
Mirage Energy (PK) (USOTC:MRGE)
Historical Stock Chart
From Nov 2023 to Nov 2024