SEC Form 3
FORM 3 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES

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*
PETERSON JEFFREY S

(Last) (First) (Middle)
539 BLACKHAWK LANE

(Street)
ALPINE UT 84004

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
12/16/2013
3. Issuer Name and Ticker or Trading Symbol
ACTIVECARE, INC. [ ACAR ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director X 10% Owner
X Officer (give title below) Other (specify below)
VP Finance
5. 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 Beneficially Owned
1. Title of Security (Instr. 4) 2. Amount of Securities Beneficially Owned (Instr. 4) 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 4. Nature of Indirect Beneficial Ownership (Instr. 5)
Common Stock 2,301,263 I By Bluestone Advisors, LLC
Common Stock 2,845,671 I By Wynnman's Hill, LLC
Common Stock 1,844,886 I By Tyumen Holdings, LLC
Common Stock 17,270 I By Banyan Investment Company, LLC
Common Stock 83,009 I By Keystone Partners, LLC
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 4) 2. Date Exercisable and Expiration Date (Month/Day/Year) 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) 4. Conversion or Exercise Price of Derivative Security 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 6. Nature of Indirect Beneficial Ownership (Instr. 5)
Date Exercisable Expiration Date Title Amount or Number of Shares
Series D Convertible Preferred Stock (1) (1) Common Stock 125,000 (1) I By Tyumen Holdings, LLC(1)
Warrants (2) (2) Common Stock 650,000 $1.1 I By Tyumen Holdings, LLC(2)
Explanation of Responses:
1. The Series D Preferred shares are convertible into shares of issuer's common stock at any time, at the holder's election, on a five-for-one basis, and have no expiration date. The shares were granted as compensation for services provided by the Reporting Person; however, at the Reporting Person's request, the shares were issued in the name of Tyumen Holdings, LLC, an entity owned and controlled, in part, by the Reporting Person.
2. The Warrants are exercisable at any time and expire five years from the grant date of December 12, 2013. The Warrants were granted as compensation for services provided by the Reporting Person; however, at the Reporting Person's request, the Warrants were issued in the name of Tyumen Holdings, LLC, an entity owned and controlled, in part, by the Reporting Person.
Jeffrey Peterson 11/26/2014
** 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 5 (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).
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