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) 04/02/2014 |
3. Issuer Name and Ticker or Trading Symbol
PureSafe Water Systems, Inc. [ PSWS ] |
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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 | 25,375,000 | I | See Footnote(1) |
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 | ||||
$75,000 Convertible Promissory Note | 01/31/2014 | (4) | Common Stock | 26,785,714 | $0.0028 | I | See Footnote(2) |
Common Stock Purchase Warrant | 06/08/2012 | 06/08/2019 | Common Stock | 500,000 | $0.05 | I | See Footnote(3) |
Explanation of Responses: |
1. Owned directly by ASC Recap LLC. The Reporting Person is the manager of ASC and has voting and investment control over the securities held by ASC, but disclaims beneficial ownership of such shares. |
2. The $75,000 convertible note is convertible into 26,785,714 shares of common stock as at June 23, 2014, and is owned directly by Tarpon Bay Partners LLC. The Reporting Person is the manager of Tarpon and has voting and investment control over the securities held by Tarpon, but disclaims beneficial ownership of such shares. |
3. The Common Stock Purchase Warrant to purchase $500,000 shares of common stock of the Company is owned directly by Southridge Partners II, LP. The Reporting Person is the manager of the general partner of Southridge Partners II LP and has voting and investment control over the securities held by Southridge, but disclaims beneficial ownership of such shares. |
4. NA |
/s/ Stephen Hicks | 06/30/2014 | |
** 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. |