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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | 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. | SEC 2270 (9-02) |
1. Title of Derivative Security (Instr. 3) |
2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction 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 (Month/Day/Year) |
7. Title and Amount of Underlying Securities (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) |
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(A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Cosman Jeffrey Scott 12540 BROADWELL ROAD SUITE 2104 MILTON, GA 30004 |
 X |  X |  CEO, Chairman |  |
/s/ Jeffrey Cosman | 02/01/2017 | |
**Signature of Reporting Person | Date |
* | 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). |
(1) | Effective November 3, 2016, the Issuer completed a 1-for-20 reverse stock split. All share amounts contained herein reflect such reverse stock split. |
(2) | Effective November 30, 2016, pursuant to approval by FINRA, Here To Serve Holding Corporation (?Here To Serve?), a Delaware corporation that owned 166,140 shares of the common stock of the Issuer, completed the distribution of all such shares to its shareholders on a pro rata basis as of October 13, 2016. Accordingly, Mr. Cosman received 104,991 shares of the Issuer?s common stock based on, and in proportion to, his ownership of common stock of Here To Serve. Mr. Cosman is the Chief Executive Officer and sole director of Here To Serve and, accordingly, until the date of such dividend, Mr. Cosman had sole voting and dispositive power of such 166,140 shares of the common stock of the Issuer owned by Here To Serve. Based on Mr. Cosman?s ownership interest in Here To Serve, prior to such distribution, he beneficially owned indirectly 104,991 shares of 166,140 shares of the Issuer?s common stock owned by Here To Serve. Pursuant to Here To Serve?s distribution of shares of common stock of the Issuer, Mr. Cosman received 104,991 shares of the Issuer?s common stock based on, and in proportion to, his ownership of common stock of Here To Serve, beneficially owning such shares directly. |
(3) | This amount is comprised of (i) 499,020 shares of common stock owned directly by Mr. Cosman and (ii) 1,560 shares owned by Rush the Puck, LLC, a limited liability company in which Mr. Cosman is the majority member. |