| 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*
(Street)
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2. Issuer Name and Ticker or Trading Symbol
COUPON EXPRESS, INC. [ CPXP ] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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3. Date of Earliest Transaction
(Month/Day/Year) 05/31/2012 | ||||||||||||||||||||||||||
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4. If Amendment, Date of Original Filed
(Month/Day/Year) |
6. Individual or Joint/Group Filing (Check Applicable Line)
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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) | 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 | ||||||
| Common Stock | 833,000 | D(1) | ||||||||
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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 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 | ||||||||
| Cumulative Convertible Senior Note(4)(5) | (4)(5) | 05/31/2012 | P | $400,000 | 05/31/2012 | 05/31/2013 | Common Stock | 20,000,000 | $400,000 | 70,000,000 | I | See Footnote(2)(3) | |||
| Common Stock Warrants(4)(5) | $0.04 | 05/31/2012 | P | 20,000,000 | 05/31/2012 | 05/31/2017 | Common Stock | 20,000,000 | (4)(5) | 70,000,000 | I | See Footnote(2)(3) | |||
1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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| Explanation of Responses: |
| 1. These shares of Common Stock were granted to Joseph Heller as a result of his election as a Director of Coupon Express, Inc. (500,000 shares) and as Chairman of the Operations Committee of the Board of Directors (333,000 shares). |
| 2. The Reported securities are owned by NextLevel VIII, LLC ("NextLevel"). Joseph Heller ("Mr. Heller") and Anita Kaufman ("Ms. Kaufman") serve as the managers of NextLevel and may be deemed to beneficially own the securities held by NextLevel. The Anita Kaufman Family Partnership, LP ("AKFP") and the Anita Kaufman NextLevel VIII Trust FBO Joseph Heller ("AK Trust") each own 50% of the membership interests of NextLevel and may be deemed to beneficially own the securities held by NextLevel. AKFP-GP, LLC ("AKFP-GP") is the general partner of AKFP and Ms. Kaufman by virtue of her position as the managing member of AKFP-GP may be deemed to beneficially own the securities held by AKFP-GP and NextLevel. Mr. Heller as a beneficiary under the AK Trust may be deemed to beneficially own the securities of AK Trust. |
| 3. The Reporting Persons disclaim beneficial ownership of the reported securities except to the extent of his, her or its pecuniary interest therein and this report shall not be deemed an admission that such Reporting Person is the beneficial owners of the securities for purposes of Section 16 of the Securities Exchange Act of 1934, as amended, or for any other purpose. |
| 4. On May31, 2012, the Issuer and NextLevel entered into a Cumulative Convertible Senior Note and Warrant Purchase Agreement (the "Purchase Agreement") governing the issuance of up to $1,537,500 aggregate principal amount of Cumulative Convertible Senior Notes ("Senior Notes") and Warrants. Pursuant to the terms of the Purchase Agreement, NextLevel purchased $400,000 of Senior Notes and Warrants. |
| 5. The Senior Notes, mature on May 31, 2013 (subject to a one-year extension at the option of the holders of a majority in principal amount of the Senior Notes), are convertible into shares of the Company's Series A Preferred Stock ("Preferred Stock") at a rate of one share of Preferred Stock for each $25,000 of Senior Notes. Each share of Preferred Stock is convertible into 1,250,000 shares of the Issuer's Common Stock, subject to certain adjustments. The Warrants are exercisable until May 31, 2017 at a price of $.04 per share (subject to certain adjustments) and entitle the holder to purchase 1,250,000 shares of the Company's Common Stock for each $25,000 of principal amount of Senior Notes. |
| /s/ Joseph Heller | 06/04/2012 | |
| /s/ Anita Kaufman | 06/04/2012 | |
| NEXTLEVEL VIIII, LLC, /s/ Joseph Heller | 06/04/2012 | |
| ANITA KAUFMAN FAMILY PARTNERSHIP LP, /s/ Anita Kaufman | 06/04/2012 | |
| AKFP-GP, LLC, /s/ Anita Kaufman | 06/04/2012 | |
| ANITA KAUFMAN NEXTLEVEL VIII TRUST FBO JOSEPH HELLER, /s/ Joseph Heller | 06/04/2012 | |
| /s/ Lawrence Pecoraro | 06/04/2012 | |
| ** 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. | ||