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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES 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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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 1474 (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 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) |
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Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||||||
Common Stock Purchase Warrants | $ 1 (2) | 11/23/2004 | X | 500,000 | 05/17/2003 | 05/17/2008 | Common Stock | 500,000 | $ 0 | 0 | D | ||||
Common Stock Purchase Warrants | $ 0.50 (2) | 11/23/2004 | X | 100,000 | 05/17/2003 | 05/17/2008 | Common Stock | 100,000 | $ 0 | 0 | D | ||||
Common Stock Purchase Warrants (2) | $ 1.50 | 11/23/2004 | A | 120,000 | 11/23/2004 | 11/23/2007 | Common Stock | 120,000 | $ 0 | 120,000 | D |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
DEARHOLT STEPHEN M 759 NORTH MILWAUKEE STREET SUITE 319 MILWAUKEE, WI 53202 |
X | X |
James M. Bedore, Attorney-in-fact | 11/23/2004 | |
**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) | The reporting person is also deemed to beneficially own 23,900 shares held by his self-directed IRA, 69,500 shares held by a profit sharing plan, of which the reporting person is a beneficiary, 9,680 shares held by a money purchase plan, of which the reporting person is a beneficiary, 275,820 shares held by a trust, of which the reporting person is a trustee, 18,100 shares held by the reporting person's minor child and 418,100 shares held by a trust, of which the reporting person is a trustee. |
(2) | Each common stock purchase warrant was originally convertible into one share of common stock upon payment of the per warrant exercise price. The conversion rate was subsequently amended to grant the holder of the warrants an additional number of common stock purchase warrants upon conversion equal to 20% of the aggregate number of common stock purchase warrants exercised. As a result, because the holder of the warrants exercised a total of 600,000 common stock purchase warrants, the holder received an additional 120,000 common stock purchase warrants. |