SEC FORM 4 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*
Torgerson Family Trust

(Last) (First) (Middle)
596 MCCLURE ROAD

(Street)
KELOWNA A1 V1W 1H3

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
Civeo Corp [ CVEO ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director X 10% Owner
Officer (give title below) Other (specify below)
3. Date of Earliest Transaction (Month/Day/Year)
12/19/2018
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
Class A Series 1 Preferred Shares $3.3 12/19/2018 J(1) 637 (2) (3) Common Stock 1,930,303.011(4) $9,448.33(5) 9,042 D
Explanation of Responses:
1. Forfeiture of shares pursuant to escrow agreement entered into on April 2, 2018 in connection with the acquisition of Noralta Lodge Ltd. by the Issuer. The shares were forfeited in connection with a post-closing purchase price adjustment.
2. The Preferred Shares can be converted by the issuer at any time if the 15-day volume weighted average price of the Common Shares is equal to or exceeds the Conversion Price; the holders of the Preferred Shares will have the right to convert the Preferred Shares into Common Shares at any time after April 2, 2020.
3. The Preferred Shares mandatorily convert after five years from the date of issuance.
4. The Preferred Shares are convertible into the number of Common Shares at a rate of 3,030.3030 Common Shares per each $10,000 of Liquidation Preference. The Preferred Shares have an initial Liquidation Preference of $10,000 per share, which amount may be increased in connection with the accrual of dividends or the payment of in-kind dividends.
5. Pursuant to the escrow agreement, the shares were to be valued at CAD$12,708 for purposes of the purchase price adjustment. $9,448.33 represents the the USD equivalent of CAD$12,708 based on the exchange rate on December 19, 2018.
Remarks:
/s/ Lance Torgerson, Trustee 03/08/2019
** 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).
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