Annual Statement of Changes in Beneficial Ownership (5)
15 Février 2017 - 4:41PM
Edgar (US Regulatory)
FORM 5
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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).
[
X
]
Form 3 Holdings Reported
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Form 4 Transactions Reported
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0362
Estimated average burden
hours per response...
1.0
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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
*
AMERICATOWNE Inc.
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2. Issuer Name
and
Ticker or Trading Symbol
ATI Modular Technology Corp. [GREI]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
_____ Director
__
X
__ 10% Owner
_____ Officer (give title below)
_____ Other (specify below)
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(Last)
(First)
(Middle)
4700 HOMEWOOD COURT, SUITE 100
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3. Statement for Issuer's Fiscal Year Ended
(MM/DD/YYYY)
12/31/2016
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(Street)
RALEIGH, NC 27609
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
___ Form Filed by One Reporting Person
_
X
_ Form Filed by More than One Reporting Person
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security
(Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code
(Instr. 8)
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4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I)
(Instr. 4)
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7. Nature of Indirect Beneficial Ownership
(Instr. 4)
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Amount
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(A) or (D)
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Price
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Common Stock
(1)
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3
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100000000
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D
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Common Stock
(2)
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3
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101629
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D
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Common Stock
(3)
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3
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100101629
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I
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Via AmericaTowne, Inc. and The Alton & Xiang Mei Lin Perkins Family Trust
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Common Stock
(4)
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3
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15694
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D
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Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (
e.g.
, puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 3)
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2. Conversion or Exercise Price of Derivative Security
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3. Trans. Date
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3A. Deemed Execution Date, if any
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4. Trans. Code
(Instr. 8)
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5. Number of Derivative Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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6. Date Exercisable and Expiration Date
(MM/DD/YYYY)
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7. Title and Amount of Securities Underlying Derivative Security
(Instr. 3 and 4)
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8. Price of Derivative Security
(Instr. 5)
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9. Number of Derivative Securities Beneficially Owned at End of Issuer's Fiscal Year
(Instr. 4)
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10. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
(Instr. 4)
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11. Nature of Indirect Beneficial Ownership
(Instr. 4)
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(A)
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(D)
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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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Explanation of Responses:
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(
1)
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Held by AmericaTowne, Inc. For further information, please see the Form 3 filed by AmericaTowne, Inc. on October 17, 2016.
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(
2)
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The Alton & Xiang Mei Lin Perkins Family Trust ("Perkins Trust") acquired shares of common stock of the Issuer in the open market between June 13, 2016 and September 13, 2016 as disclosed on the SC 13D/A filed on September 16, 2016.
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(
3)
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Held indirectly by Alton Perkins, as indicated above.
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(
4)
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Held directly by Alton Perkins.
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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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AMERICATOWNE Inc.
4700 HOMEWOOD COURT
SUITE 100
RALEIGH, NC 27609
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X
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Alton & Xiang Mei Lin Perkins Family Trust
4700 HOMEWOOD COURT
SUITE 100
RALEIGH, NC 27609
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Related to Alton Perkins.
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PERKINS ALTON
4700 HOMEWOOD COURT
SUITE 100
RALEIGH, NC 27609
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X
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X
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COB, CEO, CFO
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Signatures
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Leisanne Smeadala, Limited Power of Attorney for Alton Perkins on behalf of AmericaTowne, Inc.
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2/14/2017
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**
Signature of Reporting Person
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Date
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Leisanne Smeadala, Limited Power of Attorney for Alton Perkins on behalf of Alton & Xiang Mei Lin Perkins Family Trust
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2/14/2017
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**
Signature of Reporting Person
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Date
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Leisanne Smeadala, Limited Power of Attorney for Alton Perkins
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2/14/2017
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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 4(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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