0001209191-20-062930.txt : 20201211 0001209191-20-062930.hdr.sgml : 20201211 20201211161704 ACCESSION NUMBER: 0001209191-20-062930 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20200827 FILED AS OF DATE: 20201211 DATE AS OF CHANGE: 20201211 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: SIEBEL THOMAS M CENTRAL INDEX KEY: 0001031530 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39744 FILM NUMBER: 201383755 MAIL ADDRESS: STREET 1: SIEBEL SYSTEMS INC STREET 2: 2207 BRIDGEPOINTE PARKWAY CITY: SAN MATEO STATE: CA ZIP: 94404 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Siebel Living Trust u/a/d 7/27/93, as amended CENTRAL INDEX KEY: 0001834425 STATE OF INCORPORATION: CA FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39744 FILM NUMBER: 201383756 BUSINESS ADDRESS: STREET 1: C/O C3.AI, INC. STREET 2: 1300 SEAPORT BLVD., SUITE 500 CITY: REDWOOD CITY STATE: CA ZIP: 94063 BUSINESS PHONE: 650-503-2200 MAIL ADDRESS: STREET 1: C/O C3.AI, INC. STREET 2: 1300 SEAPORT BLVD., SUITE 500 CITY: REDWOOD CITY STATE: CA ZIP: 94063 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: C3.ai, Inc. CENTRAL INDEX KEY: 0001577526 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-PREPACKAGED SOFTWARE [7372] IRS NUMBER: 263999357 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 1300 SEAPORT BLVD STREET 2: SUITE 500 CITY: REDWOOD CITY STATE: CA ZIP: 94063 BUSINESS PHONE: 650-503-2218 MAIL ADDRESS: STREET 1: 1300 SEAPORT BLVD STREET 2: SUITE 500 CITY: REDWOOD CITY STATE: CA ZIP: 94063 FORMER COMPANY: FORMER CONFORMED NAME: C3 IoT, Inc. DATE OF NAME CHANGE: 20180123 FORMER COMPANY: FORMER CONFORMED NAME: C3, Inc. DATE OF NAME CHANGE: 20130522 4 1 doc4.xml FORM 4 SUBMISSION X0306 4 2020-08-27 0 0001577526 C3.ai, Inc. AI 0001031530 SIEBEL THOMAS M C/O C3.AI, INC. 1300 SEAPORT BLVD, SUITE 500 REDWOOD CITY CA 94603 1 1 1 0 Chief Executive Officer 0001834425 Siebel Living Trust u/a/d 7/27/93, as amended C/O C3.AI, INC. 1300 SEAPORT BLVD, SUITE 500 REDWOOD CITY CA 94063 0 0 1 0 Class A Common Stock 2020-12-11 4 C 0 170294 A 170294 I See Footnote Class A Common Stock 2020-12-11 4 C 0 72695 A 72695 I See Footnote Class A Common Stock 2020-12-11 4 C 0 1335383 A 12057527 I See Footnote Class A Common Stock 2020-12-11 4 C 0 9216 A 9216 I See Footnote Class A Common Stock 2020-12-11 4 C 0 146198 A 1237115 I See Footnote Class A Common Stock 2175666 D Series B* Convertible Preferred Stock 2020-12-11 4 C 0 140165 0.00 D Class A Common Stock 140165 0 I See Footnote Series B* Convertible Preferred Stock 2020-12-11 4 C 0 59834 0.00 D Class A Common Stock 59834 0 I See Footnote Series B-1A* Convertible Preferred Stock 2020-12-11 4 C 0 30129 0.00 D Class A Common Stock 30129 0 I See Footnote Series B-1A* Convertible Preferred Stock 2020-12-11 4 C 0 12861 0.00 D Class A Common Stock 12861 0 I See Footnote Series B-1A* Convertible Preferred Stock 2020-12-11 4 C 0 38343 0.00 D Class A Common Stock 38343 0 I See Footnote Series B-1B* Convertible Preferred Stock 2020-12-11 4 C 0 9216 0.00 D Class A Common Stock 9216 0 I See Footnote Series B-1B* Convertible Preferred Stock 2020-12-11 4 C 0 45120 0.00 D Class A Common Stock 45120 0 I See Footnote Series C Convertible Preferred 2020-12-11 4 C 0 146198 0.00 D Class A Common Stock 146198 0 I See Footnote Series F Convertible Preferred 2020-12-11 4 C 0 1251920 0.00 D Class A Common Stock 1251920 0 I See Footnote Immediately upon the closing of the Issuer's initial public offering, all shares of Series B* Convertible Preferred Stock, Series B-1A* Convertible Preferred Stock, Series B-1B* Convertible Preferred Stock, Series C Convertible Preferred Stock and Series F Convertible Preferred Stock automatically converted into shares of Class A Common Stock and had no expiration date. The shares are held by Siebel Asset Management, L.P., of which the Reporting Person is the general partner. The shares are held by Siebel Asset Management III, L.P., of which the Reporting Person is the general partner. The shares are held by The Siebel Living Trust u/a/d 7/27/93, a amended, of which the Reporting Person is trustee. The shares are held by First Virtual Holdings, LLC, of which the Reporting Person is Chairman. The shares are held by The Siebel 2011 Irrevocable Children's Trust, of which the Reporting Person is co-trustee. Two of two filings made for the Reporting Persons. /s/ Brady Mickelsen, Attorney-in-Fact 2020-12-11 /s/ Brady Mickelsen, Attorney-in-Fact 2020-12-11