FORM 5 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 ANNUAL 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 |
|
|||||||||||||||
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). | |||||||||||||||||
Form 3 Holdings Reported. | |||||||||||||||||
|
Form 4 Transactions Reported. |
1. Name and Address of Reporting Person*
(Street)
|
2. Issuer Name and Ticker or Trading Symbol
OxySure Systems Inc [ OXYS ] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
|
||||||||||||||||||||||||
3. Statement for Issuer's Fiscal Year Ended
(Month/Day/Year) 12/31/2014 | ||||||||||||||||||||||||||
4. If Amendment, Date of Original Filed
(Month/Day/Year) |
6. Individual or Joint/Group Filing (Check Applicable Line)
|
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 at end of Issuer's Fiscal Year (Instr. 3 and 4) | 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 7. Nature of Indirect Beneficial Ownership (Instr. 4) | ||||||||
Amount | (A) or (D) | Price | |||||||||||||
Common stock | 14,040,761 | I | Held by JTR Investments, Limited | ||||||||||||
Common stock | 02/16/2015 | G4 | 15,000(1) | D | $0 | 14,025,761 | I | Held by JTR Investments, Limited | |||||||
Common stock | 400,000 | I | Held by The Ross Family Trust | ||||||||||||
Common stock | 379,874 | D | |||||||||||||
Common stock | 12/31/2014 | L4 | 3,950(2) | A | $0.849(3) | 383,824 | D | ||||||||
Common stock | 02/06/2015 | L4 | 9,400(4) | A | $0.693(5) | 393,224 | D | ||||||||
Common stock | 02/10/2015 | J4 | 190,000(6) | D | $0.526 | 203,224 | D | ||||||||
Common stock | 02/14/2015 | J4 | 60,000(7) | D | $0.1 | 143,224 | D | ||||||||
Common stock | 116,182 | I | Held by spouse |
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) | |||
(A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | |||||||||
Options (right to buy) | $0.25 | 07/05/2013(8) | 02/05/2024(9) | Common stock | 1,297,488 | 1,297,488(10) | D | |||||||
Options (right to buy) | $0.25 | 06/05/2013 | A | 120,000 | 04/05/2014(8) | 12/05/2019(9) | Common stock | 120,000(11) | $0 | 1,417,488 | D | |||
Options (right to buy) | $0.72 | 07/02/2014 | A | 150,000 | 07/02/2015(8) | 07/02/2022(9) | Common stock | 150,000(12) | $0 | 150,000 | I | Held by spouse |
Explanation of Responses: |
1. Bona fide gift to Ed Huntsberry, a consultant of the Company. |
2. Small acquisitions (open market purchases) under Rule 16a-6 during the period December 3, 2014 through December 31, 2014. |
3. Per share acquisition prices ranging from $.7499 to $.94, with an aggregate per share price for all the transactions of $.849. |
4. Small acquisitions (open market purchases) under Rule 16a-6 during the period January 8, 2015 through February 6, 2015. |
5. Per share acquisition prices ranging from $.645 to $.75, with an aggregate per share price for all the transactions of $.693. |
6. Transferred to Tim Hutton, the spouse of Vicki Jones, a Director of the Company as part of a settlement agreement. |
7. Transferred to Phong Le, a shareholder of the Company as part of an agreement. |
8. Represents the earliest date(s) that any options became exercisable. |
9. Represents the latest date(s) that any vested options expire. |
10. Comprises vested options issued pursuant to various employment agreements and related amendments under the Company's 2004 Stock Option Plan. |
11. Comprises vested options as at February 17, 2015; 30,000 options are issued pursuant to that certain employment agreement renewal dated June 5, 2013 and 90,000 options are issued pursuant to that certain employment agreement renewal dated June 5, 2014, under the Company's 2004 Stock Option Plan. |
12. Comprises options issued under the Company's 2004 Stock Option Plan. Options vest as to 50,000 shares on 7/2/2015; 50,000 shares on 7/2/2016; and 50,000 shares on 7/2/2017. |
/s/ Ross Julian T | 02/17/2015 | |
** 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. | ||
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 Number. |