Statement of Changes in Beneficial Ownership (4)
January 05 2018 - 1:06PM
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
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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
*
CRAWFORD MATTHEW V
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2. Issuer Name
and
Ticker or Trading Symbol
HICKOK INC
[
HICKA
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__
X
__ Director
__
X
__ 10% Owner
_____ Officer (give title below)
_____ Other (specify below)
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(Last)
(First)
(Middle)
10514 DUPONT AVE.
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3. Date of Earliest Transaction
(MM/DD/YYYY)
12/29/2017
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(Street)
CLEVELAND, OH 44108
(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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Class A Common Stock
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1232168
(4)
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I
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See Footnote
(4)
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Class A Common Stock
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3000
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D
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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 to Purchase Class A Common Stock
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$2.50
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12/20/2016
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D
(1)
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100000
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(1)
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12/30/2017
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Class A Common Stock
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100000
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(1)
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252367
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I
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See Footnote
(3)
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Warrant to Purchase Class A Common Stock
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$2.50
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12/20/2016
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A
(1)
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100000
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(1)
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12/30/2018
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Class A Common Stock
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100000
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(1)
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426489
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I
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See Footnote
(3)
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Convertible Loan Agreement
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$1.85
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12/20/2016
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D
(2)
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252367
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(2)
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12/30/2017
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Class A Common Stock
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252367
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(2)
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100000
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I
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See Footnote
(3)
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Convertible Loan Agreement
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$1.85
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12/20/2016
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A
(2)
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326489
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(2)
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12/30/2018
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Class A Common Stock
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326489
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(2)
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426489
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I
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See Footnote
(3)
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Explanation of Responses:
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(1)
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The two reported transactions involved an amendment of an outstanding warrant, resulting in the deemed cancellation of the "old" warrant and the grant of a replacement warrant.
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(2)
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The two reported transactions involved an amendment of an outstanding convertible loan agreement, resulting in the deemed cancellation of the "old" convertible loan agreement and the entry into a replacement convertible loan agreement.
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(3)
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The securities reported herein are owned directly by Roundball LLC, an Ohio limited liability company. For purposes of the Securities Exchange Act of 1934, the Reporting Person disclaims beneficial ownership of any securities, except of his pecuniary interest therein, if any, and this report shall not be deemed an admission that the Reporting Person is the beneficial owner of such securities for purposes of Section 16 or otherwise.
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(4)
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Includes 320,918 shares that are owned directly by Roundball LLC and 911,250 shares that are owned directly by First Francis Company Inc. The reporting person disclaims beneficial ownership of those shares except to the extent of his pecuniary interest therein.
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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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CRAWFORD MATTHEW V
10514 DUPONT AVE.
CLEVELAND, OH 44108
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X
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X
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Signatures
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/s/ Fred Widen, Attorney-in-fact
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1/5/2018
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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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