Annual Statement of Changes in Beneficial Ownership (5)
June 03 2021 - 8:36AM
Edgar (US Regulatory)
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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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Form 3 Holdings Reported
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Form 4 Transactions Reported
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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3235-0362
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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
*
Bloss Roger James | 2. Issuer Name and Ticker or Trading SymbolMJ Holdings, Inc. [MJNE] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
_____ Director _____ 10% Owner __X__ Officer (give title below) _____ Other (specify below) Chief Executive Officer |
(Last)
(First)
(Middle)
7320 S. RAINBOW BLVD, SUITE 102-210 | 3. Statement for Issuer's Fiscal Year Ended (MM/DD/YYYY) 12/31/2020 |
(Street)
LAS VEGAS, NV 89139
(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
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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) | 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 | | | 3 | | | | 1768562 (1) | D | |
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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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 |
Stock option (2) | $0.75 | 9/15/2020 | | A | 500000 | | 9/15/2020 | 9/15/2023 | Common stock | 500000 | $0.75 | 500000 | D | |
Explanation of Responses: |
(1) | Includes 1,000,000 shares of common stock acquired by Mr. Bloss pursuant to the Company's Regulation D private placement offering at $0.75 per share, 500,000 shares of common stock issued upon the conversion of a $250,000 convertible note, 18,562 shares of common stock issued as an interest payment against a convertible note and 250,000 shares of common stock issued for services rendered on behalf of the Company. |
(2) | On September 15, 2020, Mr. Bloss was granted an option to purchase 500,000 shares of the Company's common stock as per the terms of his Employment Agreement (the "Agreement") dated September 15, 2020. The option has an exercise price of $0.75 and expires on the three-year anniversary date of the Agreement. 250,000 shares vested upon execution of the Agreement and 250,000 shares vest at the one-year anniversary of the Agreement. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Bloss Roger James 7320 S. RAINBOW BLVD, SUITE 102-210 LAS VEGAS, NV 89139 |
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| Chief Executive Officer |
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Signatures
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/s/ Roger James Bloss | | 6/3/2021 |
**Signature of Reporting Person | Date |
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