FORM 3 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES 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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1. Name and Address of Reporting Person*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 04/15/2014 |
3. Issuer Name and Ticker or Trading Symbol
TriVascular Technologies, Inc. [ TRIV ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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5. If Amendment, Date of Original Filed
(Month/Day/Year) |
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6. Individual or Joint/Group Filing (Check Applicable Line)
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Table I - Non-Derivative Securities Beneficially Owned | |||
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1. Title of Security (Instr. 4) | 2. Amount of Securities Beneficially Owned (Instr. 4) | 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 4. Nature of Indirect Beneficial Ownership (Instr. 5) |
Common Stock | 446,060(1) | D | |
Common Stock | 103,993 | I(2) | By Christopher G. Chavez, Trustee of the Diana J. Chavez Family Irrevocable Trust |
Common Stock | 103,993 | I(3) | By Diana J. Chavez, Trustee of the Christopher G. Chavez Family Irrevocable Trust |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
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1. Title of Derivative Security (Instr. 4) | 2. Date Exercisable and Expiration Date (Month/Day/Year) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 6. Nature of Indirect Beneficial Ownership (Instr. 5) | ||
Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Stock Option (right to buy) | 02/20/2013(4) | 02/20/2023 | Common Stock | 29,720 | $3.25 | D | |
Stock Option (right to buy) | 11/01/2014(5) | 11/30/2023 | Common Stock | 168,865 | $8.93 | D | |
Stock Option (right to buy) | 02/26/2014(4) | 02/26/2024 | Common Stock | 29,720 | $12.98 | D |
Explanation of Responses: |
1. 264,199 of these shares are subject to repurchase rights by the Issuer, which lapse on a monthly basis through February 1, 2016. |
2. Shares held directly by Christopher G. Chavez, Trustee of the Diana J. Chavez Family Irrevocable Trust for which the reporting person serves as trustee. |
3. Shares held directly by Diana J. Chavez, Trustee of the Christopher G. Chavez Family Irrevocable Trust for which the reporting person's spouse serves as trustee. |
4. Fully vested. |
5. 25% of the shares underlying the option are exercisable beginning on the one year anniversary of the vesting start date and in equal monthly installments thereafter over a four-year period. |
Remarks: |
Exhibit 24 -Power of Attorney |
By: /s/ Kimberley A. Elting, Attorney-In-Fact Christopher G. Chavez | 04/15/2014 | |
** 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 5 (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. |