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*
Ross Julian T

(Last) (First) (Middle)
10880 JOHN W. ELLIOT DRIVE
SUITE 600

(Street)
FRISCO TX 75034

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
08/12/2011
3. Issuer Name and Ticker or Trading Symbol
OxySure Systems Inc [ N/A ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director X 10% Owner
X Officer (give title below) Other (specify below)
CEO, President, and Secretary
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 12,800,000 I Held by JTR Investments, Limited
Common Stock 400,000 I Held by The Ross Family Trust u/t/a Dated December 1999
Common Stock 8,000 I Held by spouse
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
Warrants 12/31/2008 12/31/2013 Common Stock 280,485 0.01 I Held by JTR Investments, Limited
Warrants 06/30/2009 06/30/2014 Common Stock 48,358 0.01 I Held by JTR Investments, Limited
Warrants 12/31/2009 12/31/2014 Common Stock 52,640 0.01 I Held by JTR Investments, Limited
Warrants 03/31/2011 03/31/2016 Common Stock 42,872 0.01 I Held by JTR Investments, Limited
Warrants 06/30/2011 06/30/2016 Common Stock 107,811 0.01 I Held by JTR Investments, Limited
Warrants 03/26/2010 03/26/2015 Common Stock 270,000 2.5 I Held by Afritex Medical Products, Ltd.
Options 01/15/2005 01/15/2015 Common Stock 108,962 0.25 D
Options 01/15/2006 01/15/2016 Common Stock 180,000 0.25 D
Options 01/15/2007 01/15/2017 Common Stock 180,000 0.25 D
Options 01/15/2008 01/15/2018 Common Stock 180,000 0.25 D
Options 01/15/2009 01/15/2019 Common Stock 180,000 0.25 D
Options 01/15/2010 01/15/2020 Common Stock 180,000 0.25 D
Options 01/15/2011 01/15/2021 Common Stock 180,000 0.25 D
Options 10/15/2011 10/15/2021 Common Stock 135,000 0.25 D
Options 03/01/2005 03/01/2015 Common Stock 16,500 0.72 I Held by spouse
Options 03/01/2006 03/01/2016 Common Stock 20,000 0.72 I Held by spouse
Options 03/01/2007 03/01/2017 Common Stock 12,500 0.72 I Held by spouse
Options 03/01/2008 03/01/2018 Common Stock 7,500 0.72 I Held by spouse
Options 03/01/2009 03/01/2019 Common Stock 5,000 0.72 I Held by spouse
Options 03/01/2010 03/01/2015 Common Stock 10,000 1 I Held by spouse
Options 03/01/2011 03/01/2016 Common Stock 10,000 1 I Held by spouse
Warrants 09/30/2008 09/30/2013 Common Stock 7,000 0.01 I Held by spouse
Convertible Securities 03/01/2008 (1) Common Stock 166,667 1.5 I Held by JTR Investments, Limited
Convertible Securities 12/31/2008 (1) Common Stock 220,700 1.5 I Held by JTR Investments, Limited
Convertible Securities 06/30/2009 (1) Common Stock 77,233 1.5 I Held by JTR Investments, Limited
Convertible Securities 12/31/2009 (1) Common Stock 61,200 1.5 I Held by JTR Investments, Limited
Convertible Securities (2) (1) Common Stock 90,000 1.5 I Held by JTR Investments, Limited
Convertible Securities 12/31/2010 (1) Common Stock 54,109 1.5 I Held by JTR Investments, Limited
Convertible Securities (3) (1) Common Stock 214,162 1.5 I Held by JTR Investments, Limited
Convertible Securities 03/26/2010 12/16/2011 Common Stock 270,000 1 I Held by Afritex Medical Products, Ltd.
Explanation of Responses:
1. The Convertible Securities can be converted by the shareholder at anytime.
2. 30,000 shares of Common Stock were exercisable as of 3/31/10; 30,000 shares of Common Stock were exercisable as of 6/30/10; and 30,000 shares of Common Stock were exercisable as of 9/30/10
3. 61,025 shares of Common Stock were exercisable as of 3/31/11 and 153,137 shares of Common Stock were exercisable as of 6/30/11
Julian T. Ross 08/24/2011
** 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).
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure.
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number.