SEC FORM 3

SEC Form 3

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^*

MOHAN RAVI

(Last)

(First)

(Middle)

C/O SHASTA VENTURES

2440 SAND HILL ROAD, SUITE 300

(Street)

MENLO PARK

94025

(City)

(State)

(Zip)

2. Date of Event Requiring Statement (Month/Day/Year)
10/11/2018

3. Issuer Name and Ticker or Trading Symbol
Anaplan, Inc. [ PLAN ]

4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)

X	Director	X	10% Owner
	Officer (give title below)		Other (specify below)

5. If Amendment, Date of Original Filed (Month/Day/Year)

6. Individual or Joint/Group Filing (Check Applicable Line)

X	Form filed by One Reporting Person
	Form filed by More than One Reporting Person

Table I - Non-Derivative Securities Beneficially Owned
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	145,304	I	By Shasta Ventures II, L.P.⁽¹⁾

Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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)
1. Title of Derivative Security (Instr. 4)	Date Exercisable	Expiration Date	Title	Amount or Number of Shares	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)
Series A Convertible Preferred Stock	⁽²⁾	⁽²⁾	Common Stock	37,569	⁽²⁾	I	By Shasta Ventures II, L.P.⁽¹⁾
Series B Convertible Preferred Stock	⁽²⁾	⁽²⁾	Common Stock	8,876,265	⁽²⁾	I	By Shasta Ventures II, L.P.⁽¹⁾
Series C Convertible Preferred Stock	⁽²⁾	⁽²⁾	Common Stock	3,136,369	⁽²⁾	I	By Shasta Ventures II, L.P.⁽¹⁾
Series D Convertible Preferred Stock	⁽²⁾	⁽²⁾	Common Stock	984,044	⁽²⁾	I	By Shasta Ventures II, L.P.⁽¹⁾
Series E Convertible Preferred Stock	⁽²⁾	⁽²⁾	Common Stock	247,547	⁽²⁾	I	By Shasta Ventures II, L.P.⁽¹⁾

Explanation of Responses:

1. Shasta Ventures II GP, LLC is the general partner of Shasta Ventures II, L.P. Ravi Mohan, a member of the issuer's Board of Directors, Robert Coneybeer, Tod Francis, and Jason Pressman are the managing members of Shasta Ventures II GP, LLC and each of them may be deemed to exercise voting and investment power over the shares held of record by Shasta Ventures II, L.P. These individuals disclaim beneficial ownership of the shares held by the aforementioned entities except to the extent of any pecuniary interest therein.

2. The reported security is convertible into the Issuer's Common Stock on a 1-for-1 basis at any time at the holder's election and shall automatically convert into Common Stock immediately prior to the closing of the Issuer's initial public offering without payment of further consideration. The shares have no expiration date.

Remarks:

	/s/ Suhani Akhare, Attorney-in-Fact	10/11/2018
	** 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.