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