0001437749-17-002230.txt : 20170213 0001437749-17-002230.hdr.sgml : 20170213 20170213161618 ACCESSION NUMBER: 0001437749-17-002230 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20161231 FILED AS OF DATE: 20170213 DATE AS OF CHANGE: 20170213 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: OMNICOMM SYSTEMS INC CENTRAL INDEX KEY: 0001034592 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-BUSINESS SERVICES, NEC [7389] IRS NUMBER: 113349762 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 2101 W COMMERCIAL BLVD. STREET 2: SUITE 3500 CITY: FORT LAUDERDALE STATE: FL ZIP: 33309 BUSINESS PHONE: 954-473-1254 MAIL ADDRESS: STREET 1: 2101 W COMMERCIAL BLVD. STREET 2: SUITE 3500 CITY: FORT LAUDERDALE STATE: FL ZIP: 33309 FORMER COMPANY: FORMER CONFORMED NAME: CORAL DEVELOPMENT CORP DATE OF NAME CHANGE: 19970225 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: WIT CORNELIS F CENTRAL INDEX KEY: 0001238906 FILING VALUES: FORM TYPE: 5 SEC ACT: 1934 Act SEC FILE NUMBER: 000-25203 FILM NUMBER: 17599331 MAIL ADDRESS: STREET 1: 2101 WEST COMMERCIAL BLVD. STREET 2: SUITE 3500 CITY: FORT LAUDERDALE STATE: FL ZIP: 33309 5 1 rdgdoc.xml FORM 5 X0306 5 2016-12-31 0 0 0001034592 OMNICOMM SYSTEMS INC OMCM 0001238906 WIT CORNELIS F 2101 W. COMMERCIAL BLVD. SUITE 3500 FORT LAUDERDALE FL 33309 1 1 1 Chief Executive Officer Common Stock 2016-08-16 5 P 0 80000 0.15 A 183334 D Common Stock 49724716 I Trust Common Stock Warrant 0.25 2016-02-29 5 A 0 450000 0.25 A 2016-02-29 2019-04-01 Common Stock 1800000 450000 D This transaction was originally reported on Form 4 filed by the Reporting Person on 8-18-16. The Transaction Code was incorrectly reported on the Form 4 and is hereby amended to reflect the correct Transaction Code. This Form 5 also corrects the end of period ownership of the Reporting Person as reported on such Form 4 by also reflecting the Reporting Person's contribution to the Cornelis F. Wit Revocable Living Trust Dated October 15, 2009 as Amended and Restated on June 11, 2015 (the "Trust"), on 1-21-2016, of 49,644,716 shares that had previously been acquired directly by the Reporting Person. The Trust is a revocable trust established by the Reporting Person as grantor with respect to which the Reporting Person is the sole trustee, and the Reporting Person, his spouse and children are beneficiaries, and, as a result, the Reporting Person may be deemed to have retained beneficial ownership of such shares. The contribution of such shares to the Trust was a change in form of beneficial ownership that was exempt from Section 16 by reason of Rule 16a-13; but should have been reflected in the amount of securities beneficially owned following reported transaction totals reported on the Form 4 filed 8-18-16. The end of the year totals in this Form 5 also reflect the Reporting Person's contribution to the Trust, on September 6, 2016, of the 80,000 shares acquired on 8-18-16. This contribution of shares to the Trust was also a change in form of beneficial ownership that was exempt from Section 16 by reason of Rule 16a-13. This transaction was originally reported on Form 4 filed by the Reporting Person on 3-2-2016. The Transaction Code was incorrectly reported on the Form 4 and is hereby amended to reflect the correct Transaction Code. /s/ Cornelis F. Wit 2017-02-13