0000899243-21-048670.txt : 20211216 0000899243-21-048670.hdr.sgml : 20211216 20211216204827 ACCESSION NUMBER: 0000899243-21-048670 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20211214 FILED AS OF DATE: 20211216 DATE AS OF CHANGE: 20211216 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: BOSTROM SUSAN L CENTRAL INDEX KEY: 0001181469 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-41140 FILM NUMBER: 211499316 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Samsara Inc. CENTRAL INDEX KEY: 0001642896 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-COMPUTER INTEGRATED SYSTEMS DESIGN [7373] IRS NUMBER: 473100039 STATE OF INCORPORATION: DE FISCAL YEAR END: 1215 BUSINESS ADDRESS: STREET 1: 1990 ALAMEDA STREET STREET 2: FLOOR 5 CITY: SAN FRANCISCO STATE: CA ZIP: 94103 BUSINESS PHONE: (415) 985-2400 MAIL ADDRESS: STREET 1: 1990 ALAMEDA STREET STREET 2: FLOOR 5 CITY: SAN FRANCISCO STATE: CA ZIP: 94103 FORMER COMPANY: FORMER CONFORMED NAME: Samsara Networks Inc. DATE OF NAME CHANGE: 20150520 4 1 doc4.xml FORM 4 SUBMISSION X0306 4 2021-12-14 0 0001642896 Samsara Inc. IOT 0001181469 BOSTROM SUSAN L C/O SAMSARA INC. 350 RHODE ISLAND STREET 4TH FLOOR, SOUTH BUILDING SAN FRANCISCO CA 94103 1 0 0 0 Class B Common Stock 0.00 2021-12-14 4 A 0 240000 0.00 A Class B Common Stock 240000 240000 D The reported shares are represented by restricted stock units, or RSUs, that vest as to 1/4 of the total shares subject to the RSU on March 15, 2022 and thereafter on a quarterly basis through March 15, 2025. The Class B Common Stock is convertible at any time, at the holder's election, into Class A Common Stock on a 1:1 basis. /s/ Adam Eltoukhy, attorney-in-fact on behalf of Susan L. Bostrom 2021-12-16