0001567619-22-018111.txt : 20221004 0001567619-22-018111.hdr.sgml : 20221004 20221004143202 ACCESSION NUMBER: 0001567619-22-018111 CONFORMED SUBMISSION TYPE: D PUBLIC DOCUMENT COUNT: 1 ITEM INFORMATION: 06b FILED AS OF DATE: 20221004 DATE AS OF CHANGE: 20221004 EFFECTIVENESS DATE: 20221004 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: 021-460666 FILM NUMBER: 221290826 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 Mateo Jaramillo 30 Dane Street Somerville MA MASSACHUSETTS 02143 Executive Officer Director Theodore Wiley 30 Dane Street Somerville MA MASSACHUSETTS 02143 Executive Officer Director Michael Skelly 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 Philip J. Deutch 30 Dane Street Somerville MA MASSACHUSETTS 02143 Director Jaimin Rangwalla 30 Dane Street Somerville MA MASSACHUSETTS 02143 Director Marc Mezvinsky 30 Dane Street Somerville MA MASSACHUSETTS 02143 Director Lorenzo Siciliano 30 Dane Street Somerville MA MASSACHUSETTS 02143 Director Other Decline to Disclose 06b false 2022-09-19 false true false 0 451799701 335399775 116399926 false 18 0 0 0 false Form Energy, Inc. /s/ Mateo Jaramillo Mateo Jaramillo Chief Executive Officer 2022-10-04