4 1 c74446ae4.htm FORM 4 Active IQ Technologies, Inc.
 

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UNITED STATES
SECURITIES AND EXCHANGE COMMISSION

Washington, DC 20549

FORM 4

STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934,
Section 17(a) of the Public Utility Holding Company Act of 1935
or Section 30(h) of the Investment Company Act of 1940

o Check this box if no longer
subject to Section 16.
Form 4 or Form 5
obligations may continue.
See Instruction 1(b)

1. Name and Address of Reporting
Person*
(Last, First, Middle)
2. Issuer Name and Ticker or
Trading Symbol
3. I.R.S. Identification Number of Reporting
Person, if an entity
(Voluntary)
  Mills, Wayne W.
  Active IQ Techonologies, Inc. (AIQT)
 
 
800 Nicollet Mall, Suite 2690

4. Statement for (Month/Day/Year) 5. If Amendment, Date of Original (Month/Day/Year)
    1/29/03
 
  (Street) 6. Relationship of Reporting Person(s) to Issuer (Check All Applicable) 7. Individual or Joint/Group Filing
(Check Applicable Line)
  Minneapolis, MN 55402
(City)                (State)           (Zip)
  x  Director o  10% Owner   x Form filed by One Reporting Person
    o  Officer (give title below)   o Form filed by More than One Reporting Person
    o  Other (specify below)  
       
     

Reminder:   Report on a separate line for each class of securities beneficially owned directly or indirectly.
 
*   If the form is filed by more than one reporting person, see instruction 4(b)(v).
 

 


 


Table I — Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned

1. Title of Security
(Instr. 3)
2. Transaction Date
(Month/Day/Year)
2a. Deemed Execution
Date, if any.

(Month/Day/Year)
3. Transaction Code
(Instr. 8)
4. Securities Acquired (A)
or Disposed of (D)

(Instr. 3, 4 and 5)
5. Amount of Securities
Beneficially Owned
Following Reported
Transactions(s)

(Instr. 3 and 4)
6. Ownership
Form:
Direct (D) or
Indirect (I)

(Instr. 4)
7. Nature of
Indirect
Beneficial
Ownership

(Instr. 4)

              Code V   Amount (A)
or
(D)
Price            

  Common Stock   1/29/03   P   4,300   A $0.30     1,134,900     D  

  Common Stock - As previously reported               150,000     I   By Spouse

  Common Stock - As previously reported               30,000     I   (1)

  Common Stock - As previously reported               271,000     I   (2)

                     

                     

                     

                   

                   

                   

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Table II — Derivative Securities Acquired, Disposed of, or Beneficially Owned
  (e.g., puts, calls, warrants, options, convertible securities)

1. Title of Derivative
Security

(Instr. 3)
2. Conversion or Exercise
Price of Derivative
Security
3. Transaction
Date

(Month/Day/Year)
3a. Deemed Execution
Date, if any

(Month/Day/Year)
4. Transaction
Code

(Instr. 8)
5. Number of Derivative Securities
Acquired (A) or Disposed of (D)

(Instr. 3, 4 and 5)

                      Code V   (A) (D)

  Warrants - As previously reported   $5.50          

  Warrants - As previously reported   $5.50          

  Warrants - As previously reported   $3.00          

  Warrants - As previously reported   $2.50          

  Warrants - As previously reported   $7.15          

  Warrants - As previously reported   $3.00          

             

             

             

             

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Table II — Derivative Securities Acquired, Disposed of, or Beneficially Owned — Continued
(e.g., puts, calls, warrants, options, convertible securities)

6. Date Exercisable and
Expiration Date

(Month/Day/Year)
7. Title and Amount
of Underlying Securities

(Instr. 3 and 4)
8. Price of Derivative
Security

(Instr. 5)
9. Number of Derivative
Securities Beneficially Owned
Following Reported Transaction(s)

(Instr. 4)
10. Ownership Form of
Derivative Security:
Direct (D) or Indirect (I)

(Instr. 4)
11. Nature of
Indirect
Beneficial
Ownership

(Instr. 4)

  Date
Exercisable
Expiration
Date
  Title Amount or
Number of
Shares
                       

  Immediately 1/31/06   Common Stock 90,000         90,000     D  

  Immediately 4/30/06   Common Stock 208,334         208,334     D  

  Immediately 5/1/06   Common Stock 500,000         500,000     I   (2)

  Immediately 5/15/05   Common Stock 100,000         100,000     D  

  Immediately 5/30/03   Common Stock 15,000         15,000     I   (2)

  Immediately 3/29/07   Common Stock 25,000         25,000     I   (2)

                 

                 

                 

                 

Explanation of Responses:

(1) By Sea Spray, Ltd., a foreign corporation of which the Reporting Person is the sole shareholder.

(2) By Blake Capital, LLC, a limited liability company, of which the Reporting Person is the sole shareholder.

/s/ Wayne W. Mills   1/31/03

**Signature of Reporting Person
 
Date


**   Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
 
Note:   File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure.
 

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