0001209191-18-055703.txt : 20181019 0001209191-18-055703.hdr.sgml : 20181019 20181019165700 ACCESSION NUMBER: 0001209191-18-055703 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20181019 FILED AS OF DATE: 20181019 DATE AS OF CHANGE: 20181019 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: HINCKLEY GREGORY K CENTRAL INDEX KEY: 0001239182 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38701 FILM NUMBER: 181130922 MAIL ADDRESS: STREET 1: C/OMENTOR GRAPHICS CORP STREET 2: 8005 SW BOECKMAN ROAD CITY: WILSONVILLE STATE: OR ZIP: 97070-7777 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: SI-BONE, Inc. CENTRAL INDEX KEY: 0001459839 STANDARD INDUSTRIAL CLASSIFICATION: SURGICAL & MEDICAL INSTRUMENTS & APPARATUS [3841] IRS NUMBER: 262216351 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 471 EL CAMINO REAL, SUITE 101 CITY: SANTA CLARA STATE: CA ZIP: 95050 BUSINESS PHONE: 4082070700 MAIL ADDRESS: STREET 1: 471 EL CAMINO REAL, SUITE 101 CITY: SANTA CLARA STATE: CA ZIP: 95050 FORMER COMPANY: FORMER CONFORMED NAME: SI-Bone Inc. DATE OF NAME CHANGE: 20090326 4 1 doc4.xml FORM 4 SUBMISSION X0306 4 2018-10-19 0 0001459839 SI-BONE, Inc. SIBN 0001239182 HINCKLEY GREGORY K C/O SI-BONE, INC. 471 EL CAMINO REAL, SUITE 101 SANTA CLARA CA 95050 1 0 0 0 Common Stock 2018-10-19 4 C 0 15873 A 27937 D Common Stock 2018-10-19 4 C 0 12854 A 40791 D Common Stock 2018-10-19 4 C 0 9641 A 30752 D Common Stock 2018-10-19 4 C 0 44851 A 75603 D Series 4 Preferred Stock 2018-10-19 4 C 0 15873 D Common Stock 15873 0 D Series 6 Preferred Stock 2018-10-19 4 C 0 12141 D Common Stock 12854 0 D Series 6 Preferred Stock 2018-10-19 4 C 0 9106 D Common Stock 9641 0 D Series 7 Preferred Stock 2018-10-19 4 C 0 44851 D Common Stock 44851 0 D The Issuer's Series 4 Preferred Stock and Series 7 Preferred Stock automatically converted into an equal number of shares of Issuer's common stock immediately upon the closing of the Issuer's initial public offering and has no expiration date. The Issuer's Series 6 Preferred Stock automatically converted into approximately 1.05878 shares of Issuer's common stock immediately upon the closing of the Issuer's initial public offering and has no expiration date. Shares held by Gregory K. Hinckley and Mary C. Hinckley as Community Property with the Right of Survivorship. /s/ Gregory K. Hinckley 2018-10-19