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*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 10/16/2018 |
3. Issuer Name and Ticker or Trading Symbol
SI-BONE, Inc. [ SIBN ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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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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Table I - Non-Derivative Securities Beneficially Owned | |||
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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) |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
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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) | ||
Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Series 4 Preferred Stock | (1) | (1) | Common Stock | 2,213,425 | (1) | I | By Skyline Venture Partners V, L.P.(2) |
Series 5 Preferred Stock | (1) | (1) | Common Stock | 776,678 | (1) | I | By Skyline Venture Partners V, L.P.(2) |
Series 6 Preferred Stock | (3) | (3) | Common Stock | 652,347 | (3) | I | By Skyline Venture Partners V, L.P.(2) |
Series 7 Preferred Stock | (1) | (1) | Common Stock | 398,676 | (1) | I | By Skyline Venture Partners V, L.P.(2) |
Warrant (right to buy) | (4) | (4) | Series 5 Preferred Stock | 39,421 | $9.1 | I | By Skyline Venture Partners V, L.P.(2) |
Stock Option (right to buy) | (5) | 03/01/2027 | Common Stock | 22,222 | $5.94 | D |
Explanation of Responses: |
1. The Issuer's Series 4 Preferred Stock, Series 5 Preferred Stock and Series 7 Preferred Stock will automatically convert 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. |
2. Shares held by Skyline Venture Partners V, L.P. ("SVP V"). Skyline Venture Management V, LLC ("LLC") is the general partner of SVP V and as such may be deemed to have voting and investment power with respect to the securities of SVP V. Dr. Freund, a member of the Issuer's board of directors, together with Yasunori Kaneko, are the managing directors of LLC and each may be deemed to have voting and investment power with respect to the securities held by SVP V. Dr. Freund disclaims beneficial ownership of such securities, except to the extent of his pecuniary interest therein. |
3. The Issuer's Series 6 Preferred Stock will automatically convert 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. |
4. Shares subject to the warrant are immediately exercisable. The warrant will expire in connection with the closing of the Issuer's initial public offering. |
5. The shares subject to the option vest in equal monthly installments over three years commencing on the closing date of the Issuer's initial public offering, subject to Reporting Person's continued service through each relevant vesting date. |
Remarks: |
Exhibit 24 - Power of Attorney |
/s/ Michael A. Pisetsky, Attorney-in-Fact for John G. Freund | 10/16/2018 | |
** 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. |