0001567619-21-014103.txt : 20210728 0001567619-21-014103.hdr.sgml : 20210728 20210728163534 ACCESSION NUMBER: 0001567619-21-014103 CONFORMED SUBMISSION TYPE: D PUBLIC DOCUMENT COUNT: 1 ITEM INFORMATION: 06b FILED AS OF DATE: 20210728 DATE AS OF CHANGE: 20210728 EFFECTIVENESS DATE: 20210728 FILER: COMPANY DATA: COMPANY CONFORMED NAME: Form Energy, Inc. CENTRAL INDEX KEY: 0001717130 IRS NUMBER: 822266384 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: D SEC ACT: 1933 Act SEC FILE NUMBER: 021-408076 FILM NUMBER: 211123019 BUSINESS ADDRESS: STREET 1: 30 DANE STREET CITY: SOMERVILLE STATE: MA ZIP: 02143 BUSINESS PHONE: 844-367-6462 MAIL ADDRESS: STREET 1: 30 DANE STREET CITY: SOMERVILLE STATE: MA ZIP: 02143 FORMER COMPANY: FORMER CONFORMED NAME: Baseload Renewables, Inc. DATE OF NAME CHANGE: 20170915 D 1 primary_doc.xml X0708 D LIVE 0001717130 Form Energy, Inc. 30 DANE STREET SOMERVILLE MA MASSACHUSETTS 02143 844-367-6462 DELAWARE None Baseload Renewables, Inc. Corporation true 2017 Mateo Jaramillo 30 Dane Street Somerville MA MASSACHUSETTS 02143 Executive Officer Director Theodore A. Wiley 30 Dane Street Somerville MA MASSACHUSETTS 02143 Executive Officer Michael Skelly 30 Dane Street Somerville MA MASSACHUSETTS 02143 Director Yet-Ming Chiang 30 Dane Street Somerville MA MASSACHUSETTS 02143 Director Katie Rae 30 Dane Street Somerville MA MASSACHUSETTS 02143 Director Gabriel Kra 30 Dane Street Somerville MA MASSACHUSETTS 02143 Director David Thomas Danielson 30 Dane Street Somerville MA MASSACHUSETTS 02143 Director Massimiliano Pieri 30 Dane Street Somerville MA MASSACHUSETTS 02143 Director Philip J. Deutch 30 Dane Street Somerville, MA MASSACHUSETTS 02143 Director Jaimin Rangwalla 30 Dane Street Somerville MA MASSACHUSETTS 02143 Director Other Decline to Disclose 06b false 2021-07-21 false true false 0 199999837 155188867 44810970 false 17 0 0 0 false Form Energy, Inc. /s/ Mateo Jaramillo Mateo Jaramillo Chief Executive Officer 2021-07-28