Statement of Changes in Beneficial Ownership (4)
August 28 2018 - 5:43PM
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
*
Davis Tiffany N.
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2. Issuer Name
and
Ticker or Trading Symbol
Solis Tek, Inc./NV
[
SLTK
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__
X
__ Director
_____ 10% Owner
__
X
__ Officer (give title below)
_____ Other (specify below)
Chief Operating Officer
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(Last)
(First)
(Middle)
C/O SOLIS TEK INC., 853 SANDHILL AVENUE
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3. Date of Earliest Transaction
(MM/DD/YYYY)
8/22/2018
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(Street)
CARSON, CA 90746
(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, par value $0.001 per share
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8/22/2018
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A
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100000
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A
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$0.00
(1)
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350000
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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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Stock Option
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$0.74
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8/22/2018
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A
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1344797
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8/22/2018
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8/22/2023
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Common Stock
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1344797
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$0.00
(2)
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1344797
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D
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Stock Option
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$0.94
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8/27/2018
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A
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750000
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8/27/2018
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8/27/2023
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Common Stock
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750000
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$0.00
(3)
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750000
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D
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Explanation of Responses:
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(1)
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The shares were granted by the Issuer to Tiffany Davis for joining the Board of Directors on August 22, 2018.
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(2)
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The options were granted in connection with an employment agreement entered into between Solis Tek Inc. and Tiffany Davis, dated August 22, 2018.
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(3)
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The options were granted in connection with an amendment to employment agreement entered into between Solis Tek Inc. and Tiffany Davis, dated August 27, 2018, which options were given in lieu of 750,000 shares of common granted to Tiffany Davis pursuant to the employment agreement entered into between Solis Tek Inc. and Tiffany Davis, dated August 22, 2018.
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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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Davis Tiffany N.
C/O SOLIS TEK INC.
853 SANDHILL AVENUE
CARSON, CA 90746
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X
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Chief Operating Officer
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Signatures
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/s/ TIFFANY DAVIS
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8/28/2018
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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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