1. Name and Address of Reporting Person*
2865 SAND HILL ROAD, SUITE 101 |
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(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 10/19/2021
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3. Issuer Name and Ticker or Trading Symbol
Cyngn, Inc.
[ CYN ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
|
Director |
X |
10% Owner |
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Officer (give title below) |
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Other (specify below) |
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|
|
|
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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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Form filed by One Reporting Person |
X |
Form filed by More than One Reporting Person |
|
1. Name and Address of Reporting Person*
2865 SAND HILL ROAD, SUITE 101 |
|
(Street)
Relationship of Reporting Person(s) to Issuer
|
Director |
X |
10% Owner |
|
Officer (give title below) |
|
Other (specify below) |
|
|
|
|
|
1. Name and Address of Reporting Person*
2865 SAND HILL ROAD |
SUITE 101 |
(Street)
Relationship of Reporting Person(s) to Issuer
|
Director |
X |
10% Owner |
|
Officer (give title below) |
|
Other (specify below) |
|
|
|
|
|
1. Name and Address of Reporting Person*
2865 SAND HILL ROAD |
SUITE 101 |
(Street)
Relationship of Reporting Person(s) to Issuer
|
Director |
X |
10% Owner |
|
Officer (give title below) |
|
Other (specify below) |
|
|
|
|
|
1. Name and Address of Reporting Person*
2865 SAND HILL ROAD |
SUITE 101 |
(Street)
Relationship of Reporting Person(s) to Issuer
|
Director |
X |
10% Owner |
|
Officer (give title below) |
|
Other (specify below) |
|
|
|
|
|
1. Name and Address of Reporting Person*
2865 SAND HILL ROAD |
SUITE 101 |
(Street)
Relationship of Reporting Person(s) to Issuer
|
Director |
X |
10% Owner |
|
Officer (give title below) |
|
Other (specify below) |
|
|
|
|
|
1. Name and Address of Reporting Person*
2865 SAND HILL ROAD |
SUITE 101 |
(Street)
Relationship of Reporting Person(s) to Issuer
|
Director |
X |
10% Owner |
|
Officer (give title below) |
|
Other (specify below) |
|
|
|
|
|
1. Name and Address of Reporting Person*
2865 SAND HILL ROAD |
SUITE 101 |
(Street)
Relationship of Reporting Person(s) to Issuer
|
Director |
X |
10% Owner |
|
Officer (give title below) |
|
Other (specify below) |
|
|
|
|
|
|
Andreessen Horowitz Fund III, L.P., By: AH Equity Partners III, L.L.C., Its: General Partner, By: /s/ Scott Kupor, Scott Kupor, Chief Operating Officer |
10/19/2021 |
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AH Equity Partners III, L.L.C., By: /s/ Scott Kupor, Scott Kupor, Chief Operating Officer |
10/19/2021 |
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/s/ Scott Kupor, Attorney-in-Fact for Marc L. Andreessen |
10/19/2021 |
|
Andreessen Horowitz Fund III-A, L.P., By: AH Equity Partners III, L.L.C., Its: General Partner, By: /s/ Scott Kupor, Scott Kupor, Chief Operating Officer |
10/19/2021 |
|
Andreessen Horowitz Fund III-B, L.P., By: AH Equity Partners III, L.L.C., Its: General Partner, By: /s/ Scott Kupor, Scott Kupor, Chief Operating Officer |
10/19/2021 |
|
Andreessen Horowitz Fund III-Q, L.P., By: AH Equity Partners III, L.L.C., Its: General Partner, By: /s/ Scott Kupor, Scott Kupor, Chief Operating Officer |
10/19/2021 |
|
/s/ Scott Kupor, Attorney-in-Fact for Benjamin A. Horowitz |
10/19/2021 |
|
** 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. |