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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES 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 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | 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. | SEC 2270 (9-02) |
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) |
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 at End of Issuer's Fiscal Year (Instr. 4) |
10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
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(A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | |||||||||
Warrant | $ 3.6 | Â | Â | Â | Â | Â | 03/14/2013 | 03/14/2018 | Common Stock | Â | 6,875 | Â | ||
Warrant | $ 10 | Â | Â | Â | Â | Â | 01/26/2015 | 01/26/2020 | Common Stock | Â | 3,165 | Â | ||
Warrants | $ 4 | Â | Â | Â | Â | Â | 02/05/2015 | 02/05/2020 | Common Stock | Â | 914,065 | By Riverview Financial Corp | ||
Warrants | $ 4 | Â | Â | Â | Â | Â | 02/05/2015 | 02/05/2020 | Common Stock | Â | 40,250 | By Spouse |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
FIELDS RANDALL K C/O PARK CITY GROUP, INC. 299 SOUTH MAIN STREET, SUITE 2370 SALT LAKE CITY, UT 84111 |
 |  |  CHIEF EXECUTIVE OFFICER |  |
/s/ Randall K. Fields | 09/01/2015 | |
**Signature of Reporting Person | Date |
* | If the form is filed by more than one reporting person, see Instruction 4(b)(v). |
** | Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). |
(1) | Shares gifted by the Reporting Person to Charitable 2010, LLC. The Reporting Person is a member of Charitable 2010, LLC and retain investment control over the gifted shares. |
(2) | Shares issued in lieu of cash compensation at a 15% discount to fair market value, pursuant to the Issuer's 2011 Employee Stock Purchase Plan. |
(3) | The reported shares of Series B Preferred Stock were redeemed by the Issuer, pursuant to the terms and conditions of the Second Amended and Restated Certificate of Designation of the Relative Rights, Powers and Preferences of the Issuer's Series B Preferred Stock. |
(4) | Shares issued as payment of a bonus granted to Fields Management, Inc., a management company wholly-owned by the Reporting Person ("FMI"), by the Compensation Committee of the Issuer's Board of Directors, pursuant to the Employment Agreement by and between the Issuer and FMI, dated June 30, 2013, pursuant to which the Reporting Person serves as the Issuer's Chief Executive Officer. |