Statement of Changes in Beneficial Ownership (4)
January 12 2021 - 5:01PM
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
*
Deller Colin James |
2. Issuer Name and Ticker or Trading Symbol
ClearSign Technologies Corp
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CLIR
]
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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 Executive Officer |
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(Last)
(First)
(Middle)
12870 INTERURBAN AVENUE SOUTH |
3. Date of Earliest Transaction
(MM/DD/YYYY)
1/10/2021 |
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(Street)
SEATTLE, WA 98168
(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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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 |
| Option to Purchase Coomon Stock | $3.37 | 1/10/2021 | | A | | 590000 | | (1) | 1/9/2031 | Common Stock | 590000 | $0.00 | 590000 | D | |
| Option to Purchase Common Stock | $0.94 | | | | | | | (2) | 1/1/2030 | Common Stock | 182730 | | 182730 | D | |
| Option to Purchase Common Stock | $1.16 | | | | | | | (3) | 1/1/2029 | Common Stock | 400000 | | 400000 | D | |
| Option to Purchase Common Stock | $2.25 | | | | | | | (3) | 1/1/2029 | Common Stock | 200000 | | 200000 | D | |
| Explanation of Responses: |
| (1) | 80,000 shares underlying the option vested immediately upon issuance. The right to purchase the remaining option shares vests upon the achievement of certain performance goals. As each of these various performance goals is met, a portion of the award will vest and will be available for purchase from that date. |
| (2) | The right to purchase the option shares vested on the date of grant. |
| (3) | The right to purchase the option shares vests in 3 equal portions in January of 2019, 2020, 2021. |
Reporting Owners
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| Reporting Owner Name / Address | Relationships |
| Director | 10% Owner | Officer | Other |
Deller Colin James
12870 INTERURBAN AVENUE SOUTH
SEATTLE, WA 98168 | X |
| Chief Executive Officer |
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Signatures
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| /s/ Colin J. Deller | | 1/12/2021 |
| **Signature of Reporting Person | Date |
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