Statement of Changes in Beneficial Ownership (4)
May 26 2021 - 3:48PM
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).
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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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
*
Allen Mark Merle |
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)
_____ Director _____ 10% Owner __X__ Officer (give title below) _____ Other (specify below) President |
(Last)
(First)
(Middle)
4306 STONECROFT CIRCLE |
3. Date of Earliest Transaction
(MM/DD/YYYY)
12/22/2020 |
(Street)
KATY, TX 77450
(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 | 12/22/2020 | | A | | 1000000 (1) | A | $0.03 | 8957299 | D | |
Common Stock | 5/4/2021 | | J | | 333333 | A | $0.09 | 9290632 | D | |
Common Stock | 5/4/2021 | | J | | 5400000 (2) | A | $0.05 | 14690632 | D | |
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) | 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 | 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 Following Reported Transaction(s) (Instr. 4) | 10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) | 11. Nature of Indirect Beneficial Ownership (Instr. 4) |
Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Warrants to purchase Common Stock | $0.08 | 12/22/2020 | | A | | 1000000 (1) | | 12/22/2021 | 12/22/2024 | Common Stock | 1000000 | $0.08 | 1000000 | D | |
Warrants to purchase Common Stock | $0.08 | 5/4/2021 | | A | | 5400000 (2) | | 5/4/2021 | 5/4/2024 | Common Stock | 5400000 | $0.08 | 6400000 | D | |
Explanation of Responses: |
(1) | On September 1, 2020, Mr. Allen entered into an Employment Agreement to serve as President of Petrolia Energy Corporation. As part of the compensation plan Mr. Allen received an award of 1,000,000 common shares and 1,000,000 warrants exercisable at $0.08/share. |
(2) | On May 4, 2021, Mr. Allen converted $270,000 in debt to common shares at $0.05/share. Additionally, as a part of the Debt to Equity Conversion Agreement, Mr. Allen also received 5,400,000 warrants to purchase common stock at $0.08/share. The warrants are vested immediately and expire in three years. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Allen Mark Merle 4306 STONECROFT CIRCLE KATY, TX 77450 |
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| President |
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Signatures
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/s/ Mark Allen | | 5/26/2021 |
**Signature of Reporting Person | Date |
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