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*
Kendrick Donald W

(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 Technology 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 (1) 01/09/2030 Common Stock 40,000 $0.00 40,000 D
Option to Purchase Common Stock $1.21 (2) 01/01/2029 Common Stock 60,000 60,000 D
Option to Purchase Common Stock $1.21 (3) 01/01/2029 Common Stock 50,000 50,000 D
Option to Purchase Common Stock $2.25 (4) 01/01/2029 Common Stock 50,000 50,000 D
Option to Purchase Common Stock $1.9 (5) 04/01/2028 Common Stock 30,000 30,000 D
Option to Purchase Common Stock $3.8 (6) 04/01/2027 Common Stock 25,000 25,000 D
Option to Purchase Common Stock $5.07 (7) 03/31/2025 Common Stock 25,000 25,000 D
Option to Purchase Common Stock $4.21 (8) 03/31/2026 Common Stock 25,000 25,000 D
Explanation of Responses:
1. The right to purchase 20,000 option shares vested on January 9, 2020, the grant date. The remaining 20,000 option shares will vest upon the completion of certain performance objectives.
2. The right to purchase these shares vested on February 9, 2019, the grant date.
3. The right to purchase the option shares vests as follows: one-third of the option shares vested on January 1, 2019, one-third of the option shares vested on January 1, 2020 and one third of the option shares will vest on January 1, 2021.
4. The right to purchase the option shares vests as follows: one-third of the option shares vested on January 1, 2019, one-third of the option shares vested on January 1, 2020 and one third of the option shares will vest on January 1, 2021.
5. The right to purchase the option shares vests at the rate of 6.25% commencing on July 1, 2018 and continues to vest thereafter on the first 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 at the rate of 6.25% commencing on June 30, 2017 and continues to vest thereafter on the last day of each quarter until the right to purchase all of the option shares has vested.
7. The right to purchase the option shares vested 40% on April 1, 2016 and continues to vest thereafter at the rate of 5% commencing on July 1, 2016 and on each quarterly (3-month) anniversary until the right to purchase all of the shares has vested on July 1, 2020.
8. The right to purchase the option shares vested 6.25% on July 1, 2016 and continues to vest thereafter on each quarterly (3-month) anniversary until the right to purchase all of the shares has vested on July 1, 2020.
/s/ Donald Kenrick 01/14/2020
** 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.