Sec Form 4 Filing - Sample Steven L @ Acacia Diversified Holdings, Inc. - 2016-10-03

FORM 4 Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).

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, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940

OMB APPROVAL OMB Number: 3235-0287 Expires: November 30, 2011 Estimated average burden hours per response... 0.5

1. Name and Address of Reporting Person Sample Steven L 2. Issuer Name and Ticker or Trading Symbol Acacia Diversified Holdings, Inc. [ ACCA] 5. Relationship of Reporting Person(s) to Issuer (Check all applicable) X __ Director X __ 10% Owner _____ Officer (give title below) _____ Other (specify below) (Last) (First) (Middle) 3512 E. SILVER SPRINGS BLVD - #243 3. Date of Earliest Transaction (MM/DD/YY) 10/03/2016 (Street) OCALA, FL34470 4. If Amendment, Date Original Filed (MM/DD/YY) 6. Individual or Joint/Group Filing (Check Applicable Line) __ X __ Form filed by One Reporting Person _____ Form filed by More than One Reporting Person (City) (State) (Zip)

Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned 1.Title of Security (Instr. 3) 2. Transaction Date (MM/DD/YY) 2A. Deemed Execution Date, if any (MM/DD/YY) 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 11/11/2016( 1 ) G 1,491,058 ( 1 ) D $ 0 ( 2 ) 4,029,721 ( 3 ) D

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 (MM/DD/YY) 3A. Deemed Execution Date, if any (MM/DD/YY) 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 (MM/DD/YY) 7. Title and Amount of Underlying Securities (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 of Derivative Security: 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

Reporting Owners Reporting Owner Name / Address Relationships Director 10% Owner Officer Other Sample Steven L 3512 E. SILVER SPRINGS BLVD - #243 OCALA, FL34470 X X Signatures /s/ Steven L. Sample 12/16/2016 Signature of Reporting Person Date

Explanation of Responses:

( 1 )Transactions included 491,058 shares gifted on 10/31/2016 and 1,000,000 shares gifted on 11/11/2016 for a total of 1,491,058 shares. ( 2 )Shares gifted to others by the Reporting Person ( 3 )Following these gifting transactions, Reporting Person owned 4,029,721 shares of the Common stock of Issuer. 2,500,000 of those shares are currently held in trust by another person who holds a Proxy from Reporting Person to vote those shares and the Right of First Refusal to purchase those Common shares between April 4th and May 4th of 2019, but who does not currently have beneficial ownership of those shares.

Remarks: Reporting Person is reporting an ownership interest of 10% or more of the issued and outstanding Common shares of Issuer. However; Following these gifting transactions, Reporting Person owned 4,029,721 shares of the Common stock of Issuer. 2,500,000 of those shares are currently held in trust by another person who holds a Proxy from Reporting Person to vote those shares and the Right of First Refusal to purchase those Common shares between April 4th and May 4th of 2019, but who does not currently have beneficial ownership of those shares. As such, Reporting Person does not hold the influence of 10% or more of the Issuer's outstanding shares.

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.