-----BEGIN PRIVACY-ENHANCED MESSAGE----- Proc-Type: 2001,MIC-CLEAR Originator-Name: webmaster@www.sec.gov Originator-Key-Asymmetric: MFgwCgYEVQgBAQICAf8DSgAwRwJAW2sNKK9AVtBzYZmr6aGjlWyK3XmZv3dTINen TWSM7vrzLADbmYQaionwg5sDW3P6oaM5D3tdezXMm7z1T+B+twIDAQAB MIC-Info: RSA-MD5,RSA, GTd2FmbcuKRpkDwywXJwDx2gSdaty1zwgu1NoJfPXWFrNI9poEx6TRAtOwhDONHM Ghks4KqjIrUnivuxxj+seA== 0001144204-11-008460.txt : 20110214 0001144204-11-008460.hdr.sgml : 20110214 20110214184419 ACCESSION NUMBER: 0001144204-11-008460 CONFORMED SUBMISSION TYPE: SC 13G/A PUBLIC DOCUMENT COUNT: 1 FILED AS OF DATE: 20110214 DATE AS OF CHANGE: 20110214 FILED BY: COMPANY DATA: COMPANY CONFORMED NAME: KOSTIUK GARY CENTRAL INDEX KEY: 0001485033 FILING VALUES: FORM TYPE: SC 13G/A MAIL ADDRESS: STREET 1: 257 FROG POND ROAD CITY: PARKERTOWN STATE: NJ ZIP: 08087 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: POKER MAGIC INC CENTRAL INDEX KEY: 0001425355 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-AMUSEMENT & RECREATION SERVICES [7900] IRS NUMBER: 204709758 STATE OF INCORPORATION: MN FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: SC 13G/A SEC ACT: 1934 Act SEC FILE NUMBER: 005-84159 FILM NUMBER: 11609461 BUSINESS ADDRESS: STREET 1: 130 LAKE STREET WEST CITY: WAYZATA STATE: MN ZIP: 55391 BUSINESS PHONE: 952 473 3442 MAIL ADDRESS: STREET 1: 130 LAKE STREET WEST CITY: WAYZATA STATE: MN ZIP: 55391 SC 13G/A 1 v211401_sc13ga.txt SECURITIES AND EXCHANGE COMMISSION Washington, DC 20549 SCHEDULE 13G (Rule 13d-102) INFORMATION TO BE INCLUDED IN STATEMENTS FILED PURSUANT TO RULES 13d-1(b), (c), AND (d) AND AMENDMENTS THERETO FILED PURSUANT TO RULE 13d-2 (Amendment No.____1_____)* Poker Magic, Inc. - -------------------------------------------------------------------------------- (Name of Issuer) Common Stock - -------------------------------------------------------------------------------- (Title of Class of Securities) 73086A 10 1 - -------------------------------------------------------------------------------- (CUSIP Number) December 31, 2010 - -------------------------------------------------------------------------------- (Date of Event Which Requires Filing of this Statement) Check the appropriate box to designate the rule pursuant to which this Schedule is filed: [_] Rule 13d-1(b) [X] Rule 13d-1(c) [ ] Rule 13d-1(d) - ---------- * The remainder of this cover page shall be filled out for a reporting person's initial filing on this form with respect to the subject class of securities, and for any subsequent amendment containing information which would alter the disclosures provided in a prior cover page. The information required in the remainder of this cover page shall not be deemed to be "filed" for the purpose of Section 18 of the Securities Exchange Act of 1934 or otherwise subject to the liabilities of that section of the Act but shall be subject to all other provisions of the Act (however, see the Notes). CUSIP No. 73086A 10 1 13G Page 2 of 5 Pages - -------------------------------------------------------------------------------- 1. NAME OF REPORTING PERSONS Gary Kostiuk - -------------------------------------------------------------------------------- 2. CHECK THE APPROPRIATE BOX IF A MEMBER OF A GROUP* (a) [_] (b) [_] - -------------------------------------------------------------------------------- 3. SEC USE ONLY - -------------------------------------------------------------------------------- 4. CITIZENSHIP OR PLACE OF ORGANIZATION USA - -------------------------------------------------------------------------------- NUMBER OF 5. SOLE VOTING POWER SHARES 541,000 ----------------------------------------------------------------- BENEFICIALLY 6. SHARED VOTING POWER OWNED BY 0 ----------------------------------------------------------------- EACH 7. SOLE DISPOSITIVE POWER REPORTING 541,000 ----------------------------------------------------------------- PERSON 8. SHARED DISPOSITIVE POWER WITH 0 - -------------------------------------------------------------------------------- 9. AGGREGATE AMOUNT BENEFICIALLY OWNED BY EACH REPORTING PERSON 541,000 SHARES - -------------------------------------------------------------------------------- 10. CHECK IF THE AGGREGATE AMOUNT IN ROW (9) EXCLUDES CERTAIN SHARES (SEE INSTRUCTIONS) [ ] - -------------------------------------------------------------------------------- 11. PERCENT OF CLASS REPRESENTED BY AMOUNT IN ROW (9) 4.9% - -------------------------------------------------------------------------------- 12. TYPE OF REPORTING PERSON* IN - -------------------------------------------------------------------------------- CUSIP No. 73086A 10 1 13G Page 3 of 5 Pages - -------------------------------------------------------------------------------- Item 1(a). Name of Issuer: Poker Magic, Inc. - -------------------------------------------------------------------------------- Item 1(b). Address of Issuer's Principal Executive Offices: 130 Lake Street West, Suite 300, Wayzata, MN 55391 - -------------------------------------------------------------------------------- Item 2(a). Name of Person Filing: Gary Kostiuk - -------------------------------------------------------------------------------- Item 2(b). Address of Principal Business Office, or if none, Residence: 257 Frog Pond Road, Parkertown, NJ 08087 - -------------------------------------------------------------------------------- Item 2(c). Citizenship: Mr. Kostiuk is a citizen of the United States. - -------------------------------------------------------------------------------- Item 2(d). Title of Class of Securities: Common Stock - -------------------------------------------------------------------------------- Item 2(e). CUSIP Number: 73086A 10 1 - -------------------------------------------------------------------------------- Item 3. If This Statement is Filed Pursuant to ss.ss. 240.13d-1(b), or 240.13d-2(b) or (c), check whether the person filing is a: (a) [_] Broker or dealer registered under Section 15 of the Act (15 U.S.C. 78o); (b) [_] Bank as defined in Section 3(a)(6) of the Act (15 U.S.C. 78c); (c) [_] Insurance company as defined in Section 3(a)(19) of the Act (15 U.S.C. 78c); (d) [_] Investment company registered under Section 8 of the Investment Company Act of 1940 (15 U.S.C. 80a-8); (e) [_] An investment adviser in accordance with ss. 240.13d-1(b)(1)(ii)(E); (f) [_] An employee benefit plan or endowment fund in accordance with ss. 240.13d-1(b)(1)(ii)(F); (g) [_] A parent holding company or control person in accordance with ss. 240.13d-1(b)(1)(ii)(G); (h) [_] A savings association as defined in Section 3(b) of the Federal Deposit Insurance Act (12 U.S.C. 1813); (i) [_] A church plan that is excluded from the definition of an investment company under Section 3(c)(14) of the Investment Company Act (15 U.S.C. 80a-3); (j) [_] A non-U.S. institution in accordance with ss. 240.13d-1(b)(1)(ii)(J); (k) [_] Group, in accordance with ss. 240.13d-1(b)(1)(ii)(K). If filing as a non-U.S. institution in accordance with ss. 240.13d-1(b)(1)(ii)(J), please specify the type of institution: __________________. CUSIP No. 73086A 10 1 13G Page 4 of 5 Pages Item 4. Ownership. Provide the following information regarding the aggregate number and percentage of the class of securities of the issuer identified in Item 1. (a) Amount beneficially owned: 541,000 SHARES ----------------------------------------------------------------------- (b) Percent of class: 4.9% (Based upon 11,008,224 shares outstanding as of December 31, 2010 as reported by the Issuer) ---------------------------------------------------------------------- (c) Number of shares as to which such person has: (i) Sole power to vote or to direct the vote: 541,000 ----------------------- (ii) Shared power to vote or to direct the vote: 0 --------------------- (iii) Sole power to dispose or to direct the disposition of: 541,000 ---------- (iv) Shared power to dispose or to direct the disposition of: 0 -------- - -------------------------------------------------------------------------------- Item 5. Ownership of Five Percent or Less of a Class. N/A - -------------------------------------------------------------------------------- Item 6. Ownership of More Than Five Percent on Behalf of Another Person. N/A - -------------------------------------------------------------------------------- Item 7. Identification and Classification of the Subsidiary Which Acquired the Security Being Reported on by the Parent Holding Company or Control Person. N/A - -------------------------------------------------------------------------------- Item 8. Identification and Classification of Members of the Group. N/A - -------------------------------------------------------------------------------- Item 9. Notice of Dissolution of Group. N/A - -------------------------------------------------------------------------------- Item 10. Certifications. (a) Not applicable (b) Not applicable (c) By signing below I certify that, to the best of my knowledge and belief, the securities referred to above were not acquired and are not held for the purpose of or with the effect of changing or influencing the control of the issuer of the securities and were not acquired and are not held in connection with or as a participant in any transaction having that purpose or effect. SIGNATURE After reasonable inquiry and to the best of my knowledge and belief, I certify that the information set forth in this statement is true, complete and correct. Dated: February 14, 2011 /s/ Gary Kostiuk ----------------------------- Gary Kostiuk -----END PRIVACY-ENHANCED MESSAGE-----