0001144204-15-035482.txt : 20150604 0001144204-15-035482.hdr.sgml : 20150604 20150604150959 ACCESSION NUMBER: 0001144204-15-035482 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20150602 FILED AS OF DATE: 20150604 DATE AS OF CHANGE: 20150604 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: TWINLAB CONSOLIDATED HOLDINGS, INC. CENTRAL INDEX KEY: 0001590695 STANDARD INDUSTRIAL CLASSIFICATION: MEDICINAL CHEMICALS & BOTANICAL PRODUCTS [2833] IRS NUMBER: 463951742 STATE OF INCORPORATION: NV FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 632 BROADWAY STREET 2: SUITE 201 CITY: NEW YORK STATE: NY ZIP: 10012 BUSINESS PHONE: (212) 651-8500 MAIL ADDRESS: STREET 1: 632 BROADWAY STREET 2: SUITE 201 CITY: NEW YORK STATE: NY ZIP: 10012 FORMER COMPANY: FORMER CONFORMED NAME: MIRROR ME, INC. DATE OF NAME CHANGE: 20131031 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Van Andel David L CENTRAL INDEX KEY: 0001620362 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 000-55181 FILM NUMBER: 15912852 MAIL ADDRESS: STREET 1: 3133 ORCHARD VISTA DRIVE SE CITY: GRAND RAPIDS STATE: MI ZIP: 49546 4 1 v412259_form4.xml OWNERSHIP DOCUMENT X0306 4 2015-06-02 0 0001590695 TWINLAB CONSOLIDATED HOLDINGS, INC. TLCC 0001620362 Van Andel David L 3133 ORCHARD VISTA DRIVE SE GRAND RAPIDS MI 49546 1 0 1 0 common stock, par value $0.001 2015-06-02 4 P 0 3289474 .76 A 18515328 I owned through a Trust common stock, par value $0.001 2015-06-02 4 P 0 3289474 .76 A 29879474 I owned through a limited liability company Warrant (right to buy) .385 2015-06-02 4 J 0 12987012 0 A 2015-06-02 2017-09-30 Common stock, par value $0.001 12987012 12987012 I Owned through a Trust Warrant (right to buy) .01 2015-06-02 4 J 0 3289474 0 A 2015-06-02 2020-05-31 Common stock, par value $0.001 3289474 3289474 I Owned through a Trust Warrant (right to buy) .01 2015-06-02 4 J 0 3289474 0 A 2015-06-02 2020-05-31 Common stock, par value $0.001 3289474 3289474 I Owned through limited liability company Warrant (right to buy) .76 2015-06-02 4 D 0 5777411 0 D 2014-09-05 2017-09-05 Common stock, par value $0.001 5777411 0 D These shares and warrants are owned by the David L. Van Andel Trust u/a dated November 30, 1993 (the "Trust"), of which the reporting person is the sole trustee and the principal beneficiary. These shares and warrants are owned by Little Harbor, LLC, a Nevada limited liability company ("LH LLC"), of which the reporting person is the sole manager and a holder as sole trustee of the David L. Van Andel Trust u/a dated November 30, 1993 of 80.5% of the membership interests. The reporting person disclaims beneficial ownership of any shares held by LH LLC that would exceed his percentage interest in LH LLC. The per share exercise price is subject to adjustment under certain circumstances. The warrants were issued to the Trust pursuant to a Stock Purchase Agreement, dated as of June 2, 2015. The number of shares issuable upon exercise of the warrant is subject to adjustment under certain circumstances. The warrant was issued to LH LLC pursuant to a Stock Purchase Agreement, dated as of June 2, 2015. The reporting person disclaims beneficial ownership of any shares issuable to LH LLC under the warrant that would exceed his percentage interest in LH LLC. See Note 2. The warrant was canceled by mutual agreement of the reporting person and the issuer. LH LLC was issued the warrants described above as consideration for the cancellation. /s/ David L. Van Andel, Manager 2015-06-04