Statement of Changes in Beneficial Ownership (4)
May 10 2019 - 11:10AM
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)
7/12/2018
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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 Shares (Restricted)
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7/12/2018
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P
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500000
(1)
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A
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$0.065
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1416667
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I
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American Resources Offshore Inc.
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Common Shares
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10/3/2018
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P
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468750
(1)
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A
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$0.065
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1885417
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I
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American Resources Offshore Inc.
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Common Shares
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11/2/2018
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P
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547755
(2)
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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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Common Shares
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12/19/2018
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A
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156250
(3)
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A
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$0.08
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2041667
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I
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American Resources Offshore Inc.
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Common Shares
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1/15/2019
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A
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1000000
(4)
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A
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$0.05
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3589421
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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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Warrant
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$0.10
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8/17/2018
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A
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20000
(6)
(8)
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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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$0.10
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686667
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I
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American Resources Offshore Inc.
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Warrant
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$0.10
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9/30/2018
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A
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250000
(5)
(8)
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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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$0.10
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936667
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D
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Warrant
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$0.10
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12/14/2018
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A
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312500
(3)
(8)
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12/14/2018
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11/1/2020
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Common Stock
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312500
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$0.10
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1249167
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I
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American Resources Offshore Inc.
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Warrant
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$0.10
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12/31/2018
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A
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250000
(5)
(8)
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12/31/2018
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12/31/2020
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Common Stock
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250000
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$0.10
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1499167
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D
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Warrant
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$0.10
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3/31/2019
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A
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250000
(7)
(8)
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3/31/2019
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3/31/2021
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Common Stock
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250000
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$0.10
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1749167
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D
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Explanation of Responses:
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(1)
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Mr. Siem acquired these shares in a private third-party transaction at a market value of $0.065/share.
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(2)
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Mr. Siem acquired these shares in a private third-party transaction at a market value of $0.064/share.
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(3)
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Mr. Siem indirectly participated in Private Placement #4 at $0.08/share, participants also received 2x warrants for every share, exercisable for 2 years.
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(4)
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Mr. Siem acquired these shares in a private third-party transaction at a market value of $0.05/share.
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(5)
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Mr. Siem receives a 250,000-warrant issuance quarterly as part of his compensation 2018 compensation package for his service on the Board; exercisable for a 24 months period.
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(6)
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Mr. Siem indirectly participated in a Bridge Loan for $20,000 in August 2018, as part of the compensation for the loan participants received an interest rate of 12% simple interest and one (1) warrant for every dollar loaned; exercisable for one year.
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(7)
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Mr. Siem receives a 250,000-warrant issuance quarterly as part of his compensation 2019 compensation package for his service on the Board; exercisable for a 24 months period.
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(8)
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Each Warrant unit represents a contingent right to receive one share of Petrolia's common 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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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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5/10/2019
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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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