Initial Statement of Beneficial Ownership (3)
20 Marzo 2018 - 1:27PM
Edgar (US Regulatory)
FORM 3
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0104
Estimated average burden
hours per response...
0.5
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Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person
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Moynihan Patrick
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2. Date of Event Requiring Statement (MM/DD/YYYY)
2/27/2018
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3. Issuer Name
and
Ticker or Trading Symbol
Blockchain Industries, Inc. [BCII]
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(Last)
(First)
(Middle)
53 CALLE PALMERAS, 6TH FLOOR
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4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
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X
__ Director
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X
___ 10% Owner
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X
___ Officer (give title below)
_____ Other (specify below)
Chief Executive Officer /
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(Street)
SAN JUAN, PR 00901
(City)
(State)
(Zip)
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5. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
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X
_ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person
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Table I - Non-Derivative Securities Beneficially Owned
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1.Title of Security
(Instr. 4)
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2. Amount of Securities Beneficially Owned
(Instr. 4)
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3. Ownership Form: Direct (D) or Indirect (I)
(Instr. 5)
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4. Nature of Indirect Beneficial Ownership
(Instr. 5)
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Common Stock, par value $0.001
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9200000
(1)
(2)
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I
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Santa Monica Trust
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Common Stock, par value $0.001
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200000
(4)
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I
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Gretchen Moynihan - Daughter
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Common Stock, par value $0.001
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200000
(4)
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I
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Rowan Moynihan - Son
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Common Stock, par value $0.001
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200000
(4)
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I
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Sarah Moynihan - Daughter
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Common Stock, par value $0.001
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200000
(4)
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I
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Joseph Moynihan - Son
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Common Stock, par value $0.001
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200000
(3)
(4)
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I
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Lisa Moynihan - Wife
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Common Stock, par value $0.001
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100000
(4)
(5)
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I
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Lisa Moynihan - Wife
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Table II - Derivative Securities Beneficially Owned (
e.g.
, puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 4)
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2. Date Exercisable and Expiration Date
(MM/DD/YYYY)
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3. Title and Amount of Securities Underlying Derivative Security
(Instr. 4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
(Instr. 5)
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6. Nature of Indirect Beneficial Ownership
(Instr. 5)
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Date Exercisable
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Expiration Date
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Title
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Amount or Number of Shares
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Warrants
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11/29/2017
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11/28/2020
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Common Stock, par value $0.001
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100000
(3)
(4)
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$0.25
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I
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Lisa Moynihan - Wife
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Explanation of Responses:
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(1)
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Mr. Moynihan may be deemed to be the record owner 9,200,000 shares through the irrevocable Santa Monica Trust, dated May 5, 2014 and is irrevocable. Premier Trust, Inc., a Nevada trust company, is the only trustee. The named beneficiaries of the trust are the descendants of Mr. Moynihan, his mother, Carol, his sister Caroline, his sister, Patricia, Martin, his brother, and Patrick and his wife, Lisa.
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(2)
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The Trustee has no power to distribute anything to Patrick or Lisa. All distributions, if any, to Mr. Moynihan or his wife, Lisa, are made by the Power of Appointment Committee, and only the Power of Appointment Committee. The Power of Appointment Committee consists of Mr. Moynihans mother, Carol, his sister, Patricia, and Christopher D. Hagood, Lisas brother, acting on behalf of Patricks son, Rowan P. Moynihan, a minor. As a result, there are 3 members of the Committee, none of whom are Mr. Moynihan or his wife. The Power of Appointment Committee operates by a majority vote of its 3 members. While Mr. Moynihan has the authority to remove Premier Trust, Inc., as trustee and substitute another independent person or entity, he cannot remove either beneficiaries or members of the Power of Appointment Committee.
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(3)
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The securities were purchased by Lisa Moynihan, Mr. Moynihans wife, in a subscription agreement with the Company.
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(4)
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The Reporting Person disclaims beneficial ownership of these securities, and this report shall not be deemed an admission that the Reporting Person is the beneficial owner of the securities for purposes of Section 16 or for any other purpose.
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(5)
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The shares were granted to Lisa as compensation for services over a two-year period in the form of a restricted stock agreement. The shares vest at 25,000 shares on July 7, 2018, February 1, 2019, July 1, 2019, and February 1, 2020.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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Moynihan Patrick
53 CALLE PALMERAS
6TH FLOOR
SAN JUAN, PR 00901
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X
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X
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Chief Executive Officer
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Signatures
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/s/ Patrick Moynihan
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3/20/2018
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 5(b)(v).
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**
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Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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Note:
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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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Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB control number.
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