Amended Annual Statement of Changes in Beneficial Ownership (5/a)
06 Marzo 2015 - 2:39PM
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).
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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
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Champion Care Corp.
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2. Issuer Name
and
Ticker or Trading Symbol
Champion Pain Care Corp [CPAI]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
_____ Director
_____ 10% Owner
_____ Officer (give title below)
__
X
__ Other (specify below)
Controlled by directors
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(Last)
(First)
(Middle)
635 FOURTH LINE (UNIT 1)
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3. Statement for Issuer's Fiscal Year Ended
(MM/DD/YYYY)
12/31/2014
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(Street)
OAKVILLE, A6 L6L 5BO
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
2/17/2015
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6. Individual or Joint/Group Filing
(Check Applicable Line)
_
X
_ Form Filed by One Reporting Person
___ 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
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10/18/2013
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J
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31500000
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A
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$0.0001
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31500000
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D
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Common Stock
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6/13/2014
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J
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30000000
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D
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$0.0001
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1500000
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D
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Common Stock
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11/24/2014
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J
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1500000
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A
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$0.2136
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3000000
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D
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Common Stock
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11/28/2014
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J
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985000
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D
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$0.2136
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2015000
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D
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Common Stock
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11/28/2014
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J
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1500000
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D
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$0.0001
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515000
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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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Remarks:
1. On October 18, 2013, the Issuer acquired a 100% interest in Champion Pain Care Corp., a Nevada Corporation that was a wholly owned subsidiary of Champion Care Corp. ("Champion Toronto") a company incorporated in Ontario, Canada, in exchange for 31,500,000 shares of the Common Stock of the Issuer ("Shares"). Details of this transaction are provided in the Form 8-K filed on the SEC website on October 23, 2013.
2. On June 13, 2014, Champion Care Corp. transferred 7,500,000 Shares to each of Terrance Owen, Jack Fishman, Emil Schiller and Jason Gold who are all shareholders of Champion Toronto and accepted the shares for services rendered to Champion Toronto.
3. On November 24, 2014, the Issuer issued 1,500,000 new Shares to Champion Toronto for services rendered by Champion Toronto to the Issuer. The original Form 5 showed a price of $0.10 per share. This was amended to $0.2136 per share.
4. On November 28, 2014, Champion Toronto transferred 985,000 Shares to certain creditors of Champion Toronto.
5. On November 28, 2014, Champion Toronto transferred 1,500,000 Shares to Jason Gold for services rendered.
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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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Champion Care Corp.
635 FOURTH LINE (UNIT 1)
OAKVILLE, A6 L6L 5BO
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Controlled by directors
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Signatures
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/s/ Terrance Owen
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3/6/2015
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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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