0001493152-16-015575.txt : 20161201 0001493152-16-015575.hdr.sgml : 20161201 20161201121124 ACCESSION NUMBER: 0001493152-16-015575 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20160729 FILED AS OF DATE: 20161201 DATE AS OF CHANGE: 20161201 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: INCEPTION MINING INC. CENTRAL INDEX KEY: 0001416090 STANDARD INDUSTRIAL CLASSIFICATION: GOLD & SILVER ORES [1040] IRS NUMBER: 352302128 STATE OF INCORPORATION: NV FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 5330 SO 900 E STREET 2: STE 280 CITY: MURRAY STATE: UT ZIP: 84117 BUSINESS PHONE: 801-312-8113 MAIL ADDRESS: STREET 1: 5330 SO 900 E STREET 2: STE 280 CITY: MURRAY STATE: UT ZIP: 84117 FORMER COMPANY: FORMER CONFORMED NAME: GOLD AMERICAN MINING CORP. DATE OF NAME CHANGE: 20100628 FORMER COMPANY: FORMER CONFORMED NAME: SILVER AMERICA, INC. DATE OF NAME CHANGE: 20100310 FORMER COMPANY: FORMER CONFORMED NAME: GOLF ALLIANCE CORP DATE OF NAME CHANGE: 20080225 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: D'Ambrosio Trent CENTRAL INDEX KEY: 0001611150 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 000-55219 FILM NUMBER: 162027499 MAIL ADDRESS: STREET 1: 5320 SOUTH 900 EAST STREET 2: #260 CITY: MURRAY STATE: UT ZIP: 84107 4 1 form4.xml X0306 4 2016-07-29 0 0001416090 INCEPTION MINING INC. IMII 0001611150 D'Ambrosio Trent 5330 SOUTH 900 EAST, SUITE 280 MURRAY UT 84117 1 1 0 0 CFO Convertible Promissory Note 0.23 2016-07-29 2016-07-29 4 C 0 881057 200000 A 2016-01-01 2016-10-02 Common Shares 881057 0 D Common shares acquired through the exercise of a convertible promissory note (the "Note") issued to the Reporting Owner. Pursuant to the Note, the Reporting Owner was permitted to convert outstanding debt owed by the Company to shares of the Company's common stock to satisfy those debt obligations. The Reporting Owner is deemed to beneficially own one derivative security until all debt eligible for conversion under the Note has been converted to shares of the Company's common stock or the Note is amended (see Note 2, below), at which point this derivative security will be disposed of completely. As of October 2, 2016, the Reporting Owner and the Company entered into a Note Amendment through which all the convertible provisions of the Note were removed and the due date was extended until December 31, 2017. Accordingly, as of the date of this filing, there are no derivative securities underlying the Note. Assigned through Conversion of MDL Ventures, LLC convertible promissory note /s/ Trent D'Ambrosio 2016-12-01