SEC Form 4
FORM 4 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

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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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
1. Name and Address of Reporting Person*
TOLWORTHY THOMAS A

(Last) (First) (Middle)
632 BROADWAY, SUITE 201

(Street)
NEW YORK NY 10012

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
TWINLAB CONSOLIDATED HOLDINGS, INC. [ TLCC ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director X 10% Owner
X Officer (give title below) Other (specify below)
CEO & President
3. Date of Earliest Transaction (Month/Day/Year)
10/21/2015
4. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security (Instr. 3) 2. Transaction Date (Month/Day/Year) 2A. Deemed Execution Date, if any (Month/Day/Year) 3. Transaction Code (Instr. 8) 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 7. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V Amount (A) or (D) Price
Common stock, par value $0.001 10/21/2015 J(1) 3,448,276 D $1(2) 44,858,622(3)(4)(5) D
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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 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: 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
Explanation of Responses:
1. The reporting person contributed the shares of common stock that are the subject of this Form 4 to the Issuer pursuant to that certain Surrender Agreement, dated as of October 21, 2015, by and between the Issuer and the reporting person.
2. The shares contributed to the Issuer as described in note (1) above, were contributed for nominal consideration.
3. The reporting person acquired 104,000,000 shares in Twinlab Consolidated Corporation ("TCC"), now a wholly-owned subsidiary of the Issuer, on November 4, 2013 pursuant to a Restricted Stock Purchase Agreement. The shares issued were subject to time vesting only. Half the shares vested on the purchase date and the remaining half vest in 24 equal monthly installments.
4. TCC became a wholly-owned subsidiary of the Issuer pursuant to a merger on September 16, 2014 (the "Merger"). Pursuant to the Merger, each share of TCC's common stock, par value $0.0001 per share, was converted on a one-for-one basis into shares of the Issuer's common stock, subject to the same vesting conditions as the previously owned TCC common shares. 2,166,682 shares of common stock remain unvested as of the date of this filing. Unvested shares are bought back at par value if the reporting person ceases to be employed by the Issuer.
5. The reporting person acquired 1 share of TCC Series A Preferred Stock ("TCC Preferred Stock") on September 3, 2014 pursuant to a Subscription and Surrender Agreement, dated as of September 3, 2014, by and between TCC and the reporting person. Pursuant to the Merger, each share of TCC Preferred Stock was exchanged for 26,870,132 shares of the Issuer's common stock.
/s/ Thomas A. Tolworthy 10/23/2015
** Signature of Reporting Person Date
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
* 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).
Note: 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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