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*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 12/01/2011 |
3. Issuer Name and Ticker or Trading Symbol
Converted Organics Inc. [ COIN.OB ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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5. If Amendment, Date of Original Filed
(Month/Day/Year) |
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6. Individual or Joint/Group Filing (Check Applicable Line)
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Table I - Non-Derivative Securities Beneficially Owned | |||
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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 | 1,333,334 | D(1)(4)(5) | |
Common Stock | 1,333,333 | D(2)(4)(5) | |
Common Stock | 1,333,333 | D(3)(4)(5) |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
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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 |
1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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Explanation of Responses: |
1. These shares are owned directly by The Magliochetti Family 2009 Irrevocable Trust dated 01/12/09, and indirectly by Frank P. Magliochetti as co-trustee and beneficiary of such trust. Peter S. Johnson serves as co-trustee of such trust. |
2. These shares are owned directly by the LAM 2005 Trust dated 02/15/05, and indirectly by Laura A. Magliochetti as co-trustee and beneficiary of such trust. Mr. Johnson serves as co-trustee of such trust. |
3. These shares are owned directly by the ORM 2005 Trust dated 02/15/05, and indirectly by each of Olivia R. Magliochetti, as co-trustee and beneficiary of such trust, and Frank P. Magliochetti. Mr. Johnson serves as co-trustee of such trust. |
4. Mr. Johnson, in his capacity as co-trustee of each of The Magliochetti Family 2009 Irrevocable Trust dated 01/12/09, the LAM 2005 Trust dated 02/15/05 and the ORM 2005 Trust dated 02/15/05 (collectively, the "Trusts") may be deemed to own beneficially and indirectly the aggregate 4,000,000 shares of Common Stock reported herein which are deemed beneficially owned by the Trusts. |
5. Mr. Johnson, Mr. Magliochetti, Ms. Laura Magliochetti, Ms. Olivia Magliochetti and the Trusts may be deemed to be a "group" within the meaning of Section 13(d)(3) of the Securities Exchange Act of 1934, as amended. Each reporting person disclaims beneficial ownership of the shares of Common Stock reported herein except to the extent of his or its pecuniary interest therein, and expressly declares that the filing of this Form 3 shall not be construed as an admission that such reporting person is the beneficial owner of the shares of Common Stock that may be beneficially owned by any other reporting person. |
Remarks: |
Exhibit List: Exhibit 24 - Power of Attorney |
/s/ Peter S. Johnson, Trustee of The Magliochetti Family 2009 Irrevocable Trust | 12/12/2011 | |
/s/ Peter S. Johnson, Trustee of the LAM 2005 Trust | 12/12/2011 | |
/s/ Peter S. Johnson, Trustee of the ORM 2005 Trust | 12/12/2011 | |
/s/ Peter S. Johnson, attorney-in-fact for Frank P. Magliochetti | 12/12/2011 | |
/s/ Peter S. Johnson, attorney-in-fact for Laura A. Magliochetti | 12/12/2011 | |
/s/ Peter S. Johnson, attorney-in-fact for Olivia R. Magliochetti | 12/12/2011 | |
/s/ Peter S. Johnson | 12/12/2011 | |
** 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. |