0001179110-12-002506.txt : 20120214 0001179110-12-002506.hdr.sgml : 20120214 20120214163851 ACCESSION NUMBER: 0001179110-12-002506 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20111231 FILED AS OF DATE: 20120214 DATE AS OF CHANGE: 20120214 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: GARDNER HERBERT M CENTRAL INDEX KEY: 0000923414 FILING VALUES: FORM TYPE: 5 SEC ACT: 1934 Act SEC FILE NUMBER: 000-21609 FILM NUMBER: 12610840 MAIL ADDRESS: STREET 1: P O BOX 6199 CITY: FAIR HAVEN STATE: NJ ZIP: 07704 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: CHASE PACKAGING CORP CENTRAL INDEX KEY: 0001025771 STANDARD INDUSTRIAL CLASSIFICATION: AGRICULTURE SERVICES [0700] IRS NUMBER: 931216127 STATE OF INCORPORATION: NJ FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 636 RIVER ROAD CITY: FAIRHAVEN STATE: NJ ZIP: 07704 BUSINESS PHONE: 732-741-1500 MAIL ADDRESS: STREET 1: POB 6199 STREET 2: 636 RIVER ROAD CITY: FAIRHAVEN STATE: NJ ZIP: 07704 5 1 edgar.xml FORM 5 - X0304 5 2011-12-31 0 0 0 0001025771 CHASE PACKAGING CORP CPKA 0000923414 GARDNER HERBERT M P. O. BOX 463 WADING RIVER NY 11792 1 1 1 0 Vice President Series A 10% Convertible Preferred Stock 0.10 Common Stock 1864000 1864000 D Series A 10% Convertible Preferred Stock 0.10 Common Stock 262000 262000 I By spouse Currently exercisable. Not applicable. Adjusted to reflect the annual 10% stock dividend paid by the Company to all holders of Series A Convertible Preferred Stock on December 1, 2010 and December 1, 2011. Reporting person disclaims beneficial ownership of shares owned by spouse. 795 shares of Series A Convertible Preferred Stock (convertible into 795,000 Common shares) are held in reporting person's IRA Rollover. Herbert M. Gardner 2012-02-14