Unofficial Consolidation: Form 55-102F6 Insider Report
Unofficial Consolidation: Form 55-102F6 Insider Report
Ontario Securities Commission
Form 55-102F6
Unofficial consolidation current to 2017-04-13
This document is not an official statement of law or policy and should be used for reference purposes only.
FORM 55-102F6
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Notice – Collection and Use of Personal Information: The personal information required under this form is collected on behalf of and used by the securities regulatory authorities set out below for purposes of the administration and enforcement of certain provisions of the securities legislation in British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Northwest Territories, Quebec, New Brunswick, Nova Scotia, Prince Edward Island, Newfoundland and Yukon. Some of the required information will be made public pursuant to the securities legislation in each of the jurisdictions indicated above. Other required information will remain confidential and will not be disclosed to any person or company except to any of the securities regulatory authorities or their authorized representatives. If you have any questions about the collection and use of this information, you may contact the securities regulatory authority in any jurisdiction(s) in which the required information is filed, at the address(es) or telephone number(s) set out on the back of this report. |
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BOX 1. NAME OF THE REPORTING ISSUER (BLOCK LETTERS) |
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BOX 3. NAME, ADDRESS AND TELEPHONE NUMBER OF THE INSIDER (BLOCK LETTERS) |
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BOX 4. JURISDICTION(S) WHERE THE ISSUER IS A REPORTING ISSUER OR THE EQUIVALENT |
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FAMILY NAME OR CORPORATE NAME |
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GIVEN NAMES |
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□ ALBERTA □ BRITISH COLUMBIA □ MANITOBA □ NEW BRUNSWICK □ NEWFOUNDLAND □ NOVA SCOTIA
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□ PRINCE EDWARD □ ISLAND □ NORTHWEST TERRITORIES □ ONTARIO □ QUÉBEC □ SASKATCHEWAN □ YUKON |
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NO. |
STREET |
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APT |
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BOX 2. INSIDER DATA |
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RELATIONSHIP(S) TO REPORTING ISSUER |
DATE OF LAST REPORT FILED |
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MM |
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CITY |
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PROV |
POSTAL CODE |
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CHANGE IN RELATIONSHIP FROM LAST REPORT |
□ YES □ NO |
DD |
MM |
YY |
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BUSINESS TELEPHONE NUMBER |
CHANGE IN NAME, ADDRESS OR TELEPHONE NUMBER FROM LAST REPORT |
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- - EXT |
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BUSINESS FAX NUMBER - - |
□ YES □ NO |
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BOX 5. INSIDER HOLDINGS AND CHANGES (IF INITIAL REPORT, COMPLETE SECTIONS A D E AND F ONLY. SEE ALSO INSTRUCTIONS TO BOX 5)
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A A |
BB |
CC TRANSACTIONS |
DD |
EE |
FF |
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DESIGNATION OF CLASS OF SECURITIES |
BALANCE OF CLASS OF SECURITIES ON LAST REPORT |
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DATE |
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NATURE |
NUMBER/VALUE ACQUIRED |
NUMBER/VALUE DISPOSED OF |
UNIT PRICE / EXERCISE PRICE |
$ US |
PRESENT BALANCE OF CLASS OF SECURITIES HELD |
DIRECT / INDIRECT OWNERSHIP / CONTROL OR DIRECTION |
IDENTIFY THE REGISTERED HOLDER WHERE OWNERSHIP IS INDIRECT OR WHERE CONTROL OR DIRECTION IS EXERCISED |
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DD |
MM |
YY |
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BOX 6. REMARKS |
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ATTACHMENT |
□ YES □ NO |
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This form is used as a uniform report for the insider reporting requirements under all provincial securities Acts. The terminology used is generic to accommodate the various Acts. |
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The undersigned certifies that the information given in this report is true and complete in every respect. It is an offence to submit information that, in a material respect and at the time and in the light of the circumstances in which it is submitted, is misleading or untrue. BOX 7. SIGNATURE |
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CORRESPONDENCE |
□ ENGLISH □ FRENCH |
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KEEP A COPY FOR YOUR FILE |
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NAME (BLOCK LETTERS) |
SIGNATURE |
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MM |
YY |
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OSC 55-102F6 Rev. 2017 / 04 / 13 VERSION FRANCAISE DISPONIBLE SUR DEMANDE |
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DATE OF THIS REPORT |
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INSTRUCTIONS |
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Insider Reports in English and French are available from Manitoba, Ontario, Québec and New Brunswick. If you are a corporate insider in the province of Québec, you will receive correspondence in French. Individuals in the province of Québec will receive, upon request, correspondence in English. Where an insider of a reporting issuer does not own or have control or direction over securities of the reporting issuer, or where an insider’s ownership or direction or control over securities of the reporting issuer remains unchanged from the last report filed, a report is not required. Insider reports are not required to be filed in Nunavut. If you have any questions about the form you should be using to file your report, see National Instrument 55-102 System for Electronic Disclosure by Insiders (SEDI). BOX 1 Name of reporting issuer Provide the full legal name of the reporting issuer. Use a separate report for each reporting issuer. |
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List of Codes |
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BOX 5 CC Nature of transaction |
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General |
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Acquisition or disposition in the public market |
10 |
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Acquisition or disposition carried out privately |
11 |
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Acquisition or disposition under a prospectus |
15 |
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Acquisition or disposition under a prospectus exemption |
16 |
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Acquisition or disposition pursuant to a take-over bid, merger or acquisition |
22 |
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Acquisition or disposition under a purchase/ownership plan |
30 |
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Stock dividend |
35 |
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Conversion or exchange |
36 |
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Stock split or consolidation |
37 |
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Redemption/retraction/cancellation/repurchase |
38 |
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Short sale |
40 |
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Compensation for property |
45 |
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Compensation for services |
46 |
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BOX 2 Insider data Indicate all of your relationship(s) to the reporting issuer using the following codes: |
Acquisition or disposition by gift |
47 |
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Acquisition by inheritance or disposition by bequest |
48 |
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Issuer Derivatives |
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Reporting issuer that has acquired securities issued by itself |
1 |
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Grant of options |
50 |
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Subsidiary of the reporting issuer Security holder who beneficially owns or who exercises control or direction over more than 10% of the securities of the reporting issuer (Québec Securities Act – 10% of a class of shares) to which are attached voting rights or an unlimited right to a share of the profits and to its assets in case of winding up |
2 3 |
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Exercise of options |
51 |
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Expiration of options |
52 |
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Grant of warrants |
53 |
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Exercise of warrants |
54 |
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Expiration of warrants |
55 |
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Grant of rights |
56 |
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Director of a reporting issuer |
4 |
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Exercise of rights |
57 |
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Senior officer of a reporting issuer |
5 |
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Expiration of rights |
58 |
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Director or senior officer of a security holder referred to in 3 |
6 |
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Exercise for cash |
59 |
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Director or senior officer of an insider or subsidiary of the reporting issuer, other than in 4, 5 and 6 Deemed insider – 6 months before becoming an insider |
7 8 |
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Third Party Derivatives |
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Acquisition or disposition (writing) of third party derivative |
70 |
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Exercise of third party derivative |
71 |
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If you have filed a report before, indicate whether your relationship to the reporting issuer has changed. Specify the date of the last report you filed, and if it is an initial report, the date on which you became an insider. BOX 3 Name, address and telephone number of the insider Provide your name, address and business telephone number. BOX 4 Jurisdiction Indicate each jurisdiction where the issuer is a reporting issuer or the equivalent. BOX 5 Insider holdings and changes Show direct and indirect holdings separately, both in the initial report and where a transaction is reported. Indicate only one transaction per line. For an initial report complete only: A designation of class of securities held D present balance of class of securities held E nature of ownership (see List of Codes) F identification of the registered holder where ownership is not direct If you acquired or disposed of securities while an insider, complete sections A to F : A Indicate a designation of the securities traded that is sufficient to identify the class, including yield, series, maturity. B Indicate the number of securities, or for debt securities, the aggregate nominal value, of the class held, directly and indirectly, before the transaction that is being reported. C Indicate for each transaction: • the date of the transaction (not the settlement date) • the nature of the transaction (see List of Codes) • the number of securities acquired or disposed of, or for debt securities, the aggregate nominal value • the unit price paid or received on the day of the transaction, excluding the commission • if the report is in American dollars, check the space under “$ US”
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Other settlement of third party derivative |
72 |
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Expiration of third party derivative |
73 |
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Miscellaneous |
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Change in nature of ownership |
90 |
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Other |
97 |
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Correction of information |
99 |
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D Indicate the number of securities, or for debt securities, the aggregate nominal value, of the class held, directly and indirectly, after the transaction that is being reported. E Indicate the nature of ownership, control or direction of the class of securities held using the following codes: |
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Direct ownership |
1 |
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Indirect ownership (identify the registered holder) |
2 |
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Control or direction (identify the registered holder) |
3 |
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F For securities that are indirectly held, or over which control or direction is exercised, identify the registered holder. BOX 6 Remarks Add any explanation necessary to make the report clearly understandable. If space provided for any item is insufficient, additional sheets may be used. Additional sheets must refer to the appropriate Box and must be properly identified and signed. Office staff are not permitted to alter a report. BOX 7 Signature and filing Sign and date the report. File one copy of each of the report in each jurisdiction in which the issuer is reporting within the time limits prescribed by the applicable laws of that jurisdiction. Manually sign the report. Legibly print or type the name of each individual signing the report. If the report is filed on behalf of a company, partnership, trust or other entity, legibly print or type the name of that entity after the signature. If the report is signed on behalf of an individual by an agent, there shall be filed with each jurisdiction in which the report is filed a duly completed power of attorney. If the report is filled by facsimile in accordance with National instrument 55-102 System for Electronic Disclosure by Insiders (SEDI), the report should be sent to the applicable securities regulatory authority at the fax number set out below. |
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Alberta Securities Commission Suite 600, 250 0 5th Street SW Calgary, AB, T2P 0R4 Attention: Information Officer * Telephone: (403) 297-6454 Facsimile: (403) 297-6156 British Columbia Securities Commission PO Box 10142, Pacific Centre 701 West Georgia Street Vancouver, BC, V7Y 1L2 Attention: Supervisor, Insider Reporting * Telephone: (604) 899-6500 or (800) 373-6393 (in BC) Facsimile: (604) 899-6550 The Manitoba Securities Commission 500 – 400 St. Mary Avenue Winnipeg, MB, R3C 4K5 Attention: Continuous Disclosure * Telephone: (204) 945-2548 Facsimile (204) 945-0330 Financial and Consumer Services Commission 85 Charlotte Street, Suite 300 Saint John, NB, E2L 2J2 Attention: Corporate Finance Officer Telephone: (506) 658-3060 or (866) 933-2222 (in New Brunswick) Securities Commission of Newfoundland P.O. Box 8700, 2nd Floor West Block Confederation Building St. John’s, NFLD, A1B 4J6 Attention: Director of Securities * Telephone: (709) 729-4189 Facsimile: (709) 729-6187 |
Superintendent of Securities Department of Justice Government of the Northwest Territories 1st Floor, Stuart M. Hodgson Building 5009-49th Street P.O. Box 1320 Yellowknife, Northwest Territories, X1A 2L9 Attention: Deputy Superintendent of Securities Tel: (867) 920-3318 Facsimile: (867) 873-0243 Nova Scotia Securities Commission 2nd Floor, Joseph Howe Building 1690 Hollis Street, P.O. Box 458 Halifax, NS, B3J 3J9 Attention: FOI Officer * Telephone: (902) 424-7768 Facsimile: (902) 424-4625 Government of Nunavut Office of Superintendent of Securities P.O. Box 100, Station 570 1st Floor, Brown Building Iqaluit, Nunavut X0A 0H0 Contact person: Superintendent of Securities Tel: (867) 975-6590 Fax: (867) 975-6595 Email: [email protected] Ontario Securities Commission Suite 1903, Box 55, 20 Queen Street West Toronto, ON, M5H 3S8 Attention: FOI Coordinator * Telephone: (416) 593-8314 Facsimile: (416) 593-3666 Superintendent of Securities Government of Prince Edward Island 4th Floor, Shaw Building 95 Rochford Street P.O. Box 2000 Charlottetown PE C1A 7N8 Tel: (902) 368-4550 |
Autorite des marches financiers** Stock Exchange Tower P.O. Box 246, 22nd Floor 800 Victoria Square Montreal, PQ, H4Z 1G3 Attention: Responsable de l’accès à l’information Telephone: (514) 940-2150 or (800) 361-5072 (in Québec) Facsimile: (514) 873-3120 Saskatchewan Financial Services Commission Securities Division 6th Floor, 1919 Saskatchewan Drive Regina, SK, S4P 3V7 Attention: Director * Telephone: (306) 787-5645 Facsimile: (306) 787-5899 Yukon Securities Office Yukon Government Law Centre, 3rd Floor 2130 Second Avenue (PO Box 2703) Whitehorse, YT Y1A 5H6 Attn: Superintendent of Securities Tel: (867) 667-5466 Fax: (867) 393-6251 * For questions about the collection and use of personal information ** in Québec questions about the collection and use of personal information may also be addressed to the Commission d’accès à l’information du Québec (1-888-528-7741) |
OSC 55-102F6 (Reverse) Rev. 2017 / 04 / 13