|
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940 |
|
| |||||||||||||||||||||||||||||
|
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | |||
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 control number. | SEC 1474 (9-02) |
1. Title of Derivative Security (Instr. 3) |
2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) |
5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4, and 5) |
6. Date Exercisable and Expiration Date (Month/Day/Year) |
7. Title and Amount of Underlying Securities (Instr. 3 and 4) |
8. Price of Derivative Security (Instr. 5) |
9. Number of Derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) |
10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
||||
Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||||||
Common Stock Purchase Warrant | $ 0.01 | 10/30/2008 | J(1) | 750,000 | 10/30/2008 | 10/30/2015 | Common Stock | 750,000 | (2) | 6,400,000 | I | By Jurika Family Trust, U/A 1989 | |||
Series E 6% Secured Convertible Promissory Note | $ 1 (3) | 10/30/2008 | J(3) | 250,000 | 10/30/2008 | (4) | Common Stock | 250,000 | $ 250,000 | 6,650,000 | I | By Jurika Family Trust, U/A 1989 |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
JURIKA WILLIAM K 42 GLEN ALPINE ROAD PIEDMONT, CA 94611 |
X |
/s/ William K. Jurika, As Attorney-in-fact for and on behalf of himself, Michelle Jurika and the Jurika Family Trust, U/A 1989 | 10/30/2008 | |
**Signature of Reporting Person | Date |
* | If the form is filed by more than one reporting person, see Instruction 4(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). |
(1) | AXS-One issued these Common Stock Purchase Warrants to the Jurika Family Trust U/A 1989 as partial consideration for a $250,000.00 loan, as described below. |
(2) | n/a |
(3) | This Secured Convertible Promissory Note was given by AXS-One to the Jurika Family Trust U/A 1989 in connection with a $250,000.00 loan. This Note is convertible at any time, the conversion rate being $1.00, which could vary the number of shares at conversion depending on the outstanding principal and interest of the $250,000 loan at conversion. |
(4) | This Secured Convertible Promissory Note is due and payable upon the earliest occurrence of the following three events: (i) May 29, 2009, (ii) the occurrence of a "Sale Transaction" as defined therein, or (iii) upon an acceleration of this instrument. |