0001144204-12-036554.txt : 20120626 0001144204-12-036554.hdr.sgml : 20120626 20120626171343 ACCESSION NUMBER: 0001144204-12-036554 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20120509 FILED AS OF DATE: 20120626 DATE AS OF CHANGE: 20120626 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: CLEARSIGN COMBUSTION CORP CENTRAL INDEX KEY: 0001434524 STANDARD INDUSTRIAL CLASSIFICATION: INDUSTRIAL INSTRUMENTS FOR MEASUREMENT, DISPLAY, AND CONTROL [3823] IRS NUMBER: 000000000 STATE OF INCORPORATION: WA BUSINESS ADDRESS: STREET 1: 12870 INTERURBAN AVENUE SOUTH CITY: SEATTLE STATE: WA ZIP: 98168 BUSINESS PHONE: (206) 673-4848 MAIL ADDRESS: STREET 1: 12870 INTERURBAN AVENUE SOUTH CITY: SEATTLE STATE: WA ZIP: 98168 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: MARLETT CHRISTOPHER A CENTRAL INDEX KEY: 0000897744 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-35521 FILM NUMBER: 12927833 MAIL ADDRESS: STREET 1: 100 WILSHIRE BLVD CITY: SANTA MONICA STATE: CA ZIP: 90401 4 1 v317021_form4.xml OWNERSHIP DOCUMENT X0305 4 2012-05-09 1 0001434524 CLEARSIGN COMBUSTION CORP CLIR 0000897744 MARLETT CHRISTOPHER A 401 WILSHIRE BLVD., SUITE 1020 SANTA MONICA CA 90401 0 0 0 1 Former 10% Owner Common Stock 2012-05-09 4 J 0 342035 D 3593 I SEE FOOTNOTE Common Stock 2012-05-09 4 J 0 17664 A 92237 D Common Stock 2012-05-09 4 J 0 91253 A 380460 I SEE FOOTNOTE The record holder of these securities is Integrated Surgical Systems, Inc. ("ISS"). The reporting person is a shareholder, the Chief Executive Officer and one of 4 directors of ISS. On April 24, 2012, the full board of directors of ISS declared a dividend to the shareholders of ISS, of an aggregate of 450,952 shares of common stock of the Issuer. The record date of the dividend was May 9, 2012. Represents dividend shares distributed to ISS shareholders other than the reporting person (see Note 1 above). The record holder of these securities is ISS. The reporting person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein, and the inclusion of these securities in this report shall not be an admission of beneficial ownership of all of the reported securities for purposes of Section 16 or for any other purpose. Represents dividend shares distributed to the reporting person (see Note 1 above) and a change from indirect ownership to direct ownership. Represents 45,626 shares distributed to Christopher A. Marlett IRA and 45,627 shares distributed to Christopher A. Marlett Living Trust (see Note 1 above), and a change in the record holder of indirect ownership. Represents 45,626 shares held of record by Christopher A. Marlett IRA, 45,627 shares held of record by Christopher A. Marlett Living Trust and 289,207 held of record by MDB Capital Group LLC ("MDB"), of which the reporting person is the Chief Executive Officer. The reporting person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein, and the inclusion of these securities in this report shall not be an admission of beneficial ownership of all of the reported securities for purposes of Section 16 or for any other purpose. /s/ Christopher Marlett 2012-06-26