0001171843-17-005034.txt : 20170814 0001171843-17-005034.hdr.sgml : 20170814 20170814144045 ACCESSION NUMBER: 0001171843-17-005034 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20170609 FILED AS OF DATE: 20170814 DATE AS OF CHANGE: 20170814 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Monfort Edward R. CENTRAL INDEX KEY: 0001712532 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38078 FILM NUMBER: 171029390 MAIL ADDRESS: STREET 1: 620 NEWPORT CENTER DRIVE, SUITE 1100 CITY: NEWPORT BEACH STATE: CA ZIP: 92660 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: ADOMANI, INC. CENTRAL INDEX KEY: 0001563568 STANDARD INDUSTRIAL CLASSIFICATION: MOTOR VEHICLE PARTS & ACCESSORIES [3714] IRS NUMBER: 000000000 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 620 NEWPORT CENTER DRIVE STREET 2: SUITE 1100 CITY: NEWPORT BEACH STATE: CA ZIP: 92660 BUSINESS PHONE: (949) 200-4613 MAIL ADDRESS: STREET 1: 620 NEWPORT CENTER DRIVE STREET 2: SUITE 1100 CITY: NEWPORT BEACH STATE: CA ZIP: 92660 FORMER COMPANY: FORMER CONFORMED NAME: Adomani, Inc. DATE OF NAME CHANGE: 20121203 3 1 formthree.xml OWNERSHIP DOCUMENT X0206 3 2017-06-09 0 0001563568 ADOMANI, INC. ADOM 0001712532 Monfort Edward R. 2850 TOBAGO PLACE COSTA MESA CA 92626 0 1 1 0 Chief Technology Officer Common Stock 4000000 I By trust Stock Option (Right to Buy) 0.10 2020-11-01 Common Stock 12000000 D Stock Option (Right to Buy) 0.10 2022-06-01 Common Stock 3000000 D These shares are owned directly by the Monfort Revocable Living Trust, Dated 8/19/16, and indirectly by Edward R. Monfort as trustee of the trust. Edward R. Monfort is an officer and a ten percent owner of the issuer. The option vests in equal monthly installments of 1/60 of the total number of shares underlying the option beginning on November 1, 2012. The option vests in equal monthly installments of 1/60 of the total number of shares underlying the option beginning on June 1, 2014. /s/ Edward R. Monfort 2017-08-10