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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 |
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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) |
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Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
NINA FAIRBAIRN IRREVOCABLE TRUST SEPTEMBER 30, 2011 10 ORINDA VIEW ROAD ORINDA, CA 94563 |
Former 10% Owner | |||
Fairbairn Malcolm 10 ORINDA VIEW ROAD ORINDA, CA 94563 |
Former 10% Owner | |||
FAIRBAIRN EMILY 10 ORINDA VIEW ROAD ORINDA, CA 94563 |
Former 10% Owner |
NINA FAIRBAIRN IRREVOCABLE TRUST SEPTEMBER 30, 2011 By: /s/ Malcolm Fairbairn Name: Malcolm Fairbairn Title: Trustee | 01/02/2018 | |
**Signature of Reporting Person | Date | |
MALCOLM P. FAIRBAIRN /s/ Malcolm Fairbairn | 01/02/2018 | |
**Signature of Reporting Person | Date | |
EMILY FAIRBAIRN /s/Emily Fairbairn | 01/02/2018 | |
**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) | On December 28, 2017, the Nina Fairbairn Irrevocable Trust September 30, 2011 (the "Trust") transferred 133,333 shares of common stock of Energous Corporation, a Delaware corporation (the "Issuer"), to a beneficiary of the Trust. After the transfer, the Trust is no longer a 10% owner of the Issuer. |
(2) | Malcolm Fairbairn is a trustee of the Trust. After the above transfer, Malcolm Fairbairn is no longer a 10% owner of the Issuer. |
(3) | Emily Fairbairn is a trustee of the Trust. After the above transfer, Emily Fairbairn is no longer a 10% owner of the Issuer. |