0001503249-15-000016.txt : 20150518 0001503249-15-000016.hdr.sgml : 20150518 20150518112351 ACCESSION NUMBER: 0001503249-15-000016 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20150514 FILED AS OF DATE: 20150518 DATE AS OF CHANGE: 20150518 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Independence Bancshares, Inc. CENTRAL INDEX KEY: 0001311828 STANDARD INDUSTRIAL CLASSIFICATION: NATIONAL COMMERCIAL BANKS [6021] IRS NUMBER: 201734180 STATE OF INCORPORATION: SC FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 500 E. WASHINGTON STREET STREET 2: P.O. BOX 1776 CITY: GREENVILLE STATE: SC ZIP: 29602 BUSINESS PHONE: 864-672-1776 MAIL ADDRESS: STREET 1: 500 E. WASHINGTON STREET STREET 2: P.O. BOX 1776 CITY: GREENVILLE STATE: SC ZIP: 29602 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: WILLUMSTAD ROBERT B CENTRAL INDEX KEY: 0001225708 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 000-51907 FILM NUMBER: 15872262 MAIL ADDRESS: STREET 1: CITIGROUP INC/CORP LAW DEPT STREET 2: 425 PARK AVE 2ND FL CITY: NEW YORK STATE: NY ZIP: 10043 4 1 primary_doc.xml PRIMARY DOCUMENT X0306 4 2015-05-14 0 0001311828 Independence Bancshares, Inc. IEBS 0001225708 WILLUMSTAD ROBERT B 500 E. WASHINGTON ST GREENVILLE SC 29601 1 1 0 0 CHAIRMAN COMMON STOCK 1250000 D STOCK OPTION (RIGHT TO BUY) 0.65 2015-05-14 4 A 0 37500 0 A 2015-05-14 2025-05-14 COMMON STOCK 37500 37500 D SERIES A CONVERTIBLE PREFERRED STOCK 0.8 2015-05-14 4 P 0 250 0.8 A 2015-05-14 COMMON STOCK 250 250 D The Series A preferred stock is convertible into Independence Bancshares, Inc. common stock at a price per share of $0.80 per share, thus, each share of Preferred Stock would convert into 1,250 shares of Common Stock. The Series A preferred stock has no expiration date. /S/ ROBERT B. WILLUMSTAD BY NELSON MULLINS LAW FIRM WITH POWER OF ATTORNEY 2015-05-18