0001181431-13-050059.txt : 20130920 0001181431-13-050059.hdr.sgml : 20130920 20130920163645 ACCESSION NUMBER: 0001181431-13-050059 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20130918 FILED AS OF DATE: 20130920 DATE AS OF CHANGE: 20130920 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: QUANTUM FUEL SYSTEMS TECHNOLOGIES WORLDWIDE, INC. CENTRAL INDEX KEY: 0001166380 STANDARD INDUSTRIAL CLASSIFICATION: MOTOR VEHICLE PARTS & ACCESSORIES [3714] IRS NUMBER: 330933072 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 25242 ARCTIC OCEAN DRIVE CITY: LAKE FOREST STATE: CA ZIP: 92630 BUSINESS PHONE: 949-399-4500 MAIL ADDRESS: STREET 1: 25242 ARCTIC OCEAN DRIVE CITY: LAKE FOREST STATE: CA ZIP: 92630 FORMER COMPANY: FORMER CONFORMED NAME: QUANTUM FUEL SYSTEMS TECHNOLOGIES WORLDWIDE INC DATE OF NAME CHANGE: 20020201 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: MAZAIKA DAVID M CENTRAL INDEX KEY: 0001452702 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 000-49629 FILM NUMBER: 131108271 MAIL ADDRESS: STREET 1: 11226 VANDEMAN WAY CITY: SAN DIEGO STATE: CA ZIP: 92131 4 1 rrd390697.xml MAZAIKA CONVERTIBLE NOTE AND WARRANT X0306 4 2013-09-18 0 0001166380 QUANTUM FUEL SYSTEMS TECHNOLOGIES WORLDWIDE, INC. QTWW 0001452702 MAZAIKA DAVID M 25242 ARCTIC OCEAN DRIVE LAKE FOREST CA 92630 0 1 0 0 Director Strategic Development Convertible Note 2.3824 2013-09-18 4 P 0 100000 100000 A 2013-09-18 2018-09-17 common stock 100000 100000 D Warrant 2.30 2013-09-18 4 P 0 31011 0 A 2014-03-18 2019-03-17 common stock 31011 31011 D The convertible note was purchased in connection with a private placement offering of convertible notes and warrants. Represents the face value of the convertible note. The convertible note is convertible into shares of common stock, $0.02 par value, at any time after the date of issuance. Represents the scheduled maturity date of the convertible note. The maturity date is subject to a put right that may be exercised within a 30 day period following the third anniversary of the issuance date. If the put right is exercised, then the expiration date would be 90 days following the holder's exercise of the put right. The warrant was issued in connection with the issuance of the convertible note. /s/ David M. Mazaika 2013-09-20