SEC Form 4
FORM 4 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

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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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*
Fike Brian Grant

(Last) (First) (Middle)
12870 INTERURBAN AVENUE SOUTH

(Street)
SEATTLE WA 98168

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
ClearSign Technologies Corp [ CLIR ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director 10% Owner
X Officer (give title below) Other (specify below)
Chief Financial Officer
3. Date of Earliest Transaction (Month/Day/Year)
01/09/2020
4. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
Form filed by More than One Reporting Person
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 Transaction(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
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) 6. Date Exercisable and Expiration Date (Month/Day/Year) 7. Title and Amount of Securities Underlying Derivative Security (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: Direct (D) or Indirect (I) (Instr. 4) 11. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V (A) (D) Date Exercisable Expiration Date Title Amount or Number of Shares
Option to Purchase Common Stock $0.89 01/09/2020 A 40,000 01/09/2020(1) 01/09/2030 Common Stock 40,000 $0.00 40,000 D
Option to Purchase Common Stock $1.21 (2) 12/31/2028 Common Stock 50,000 50,000 D
Option to Purchase Common Stock $1.21 (3) 12/31/2028 Common Stock 50,000 50,000 D
Option to Purchase Common Stock $2.25 (3) 12/31/2028 Common Stock 50,000 50,000 D
Option to Purchase Common Stock $1.9 (4) 03/31/2028 Common Stock 25,000 25,000 D
Option to Purchase Common Stock $3.8 (5) 03/31/2027 Common Stock 10,000 10,000 D
Option to Purchase Common Stock $4.21 (6) 03/31/2026 Common Stock 5,000 5,000 D
Explanation of Responses:
1. The right to purchase the option shares vested on the date of award.
2. The right to purchase the option shares vested on the date of award.
3. The right to purchase one-third of the shares subject to the option vested as of January 1, 2019 and the right to purchase one-third of the shares subject to the option vested on January 1, 2020. The right to purchase the remaining shares will vest on January 1, 2021
4. The right to purchase the option shares vested at the rate of 6.25% commencing on July 1, 2018 and continues thereafter on the last day of each quarter. until the right to purchase all of the option shares has vested.
5. The right to purchase the option shares vested at the rate of 6.25% commencing on June 30, 2017 and continues thereafter on the last day of each quarter. until the right to purchase all of the option shares has vested.
6. The right to purchase the option shares vested 40% on 4/1/2017 and continues at the rate of 5% per quarter thereafter on the last day of each quarter, until the right to purchase all of the option shares has vested.
/s/ Brian G. Fike 01/13/2020
** Signature of Reporting Person Date
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).
** 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.
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 Number.