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