0001127602-15-015883.txt : 20150501 0001127602-15-015883.hdr.sgml : 20150501 20150501200924 ACCESSION NUMBER: 0001127602-15-015883 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20150429 FILED AS OF DATE: 20150501 DATE AS OF CHANGE: 20150501 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Facebook Inc CENTRAL INDEX KEY: 0001326801 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-COMPUTER PROGRAMMING, DATA PROCESSING, ETC. [7370] IRS NUMBER: 201665019 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 1601 WILLOW ROAD CITY: MENLO PARK STATE: CA ZIP: 94025 BUSINESS PHONE: 650-618-7714 MAIL ADDRESS: STREET 1: 1601 WILLOW ROAD CITY: MENLO PARK STATE: CA ZIP: 94025 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Koum Jan CENTRAL INDEX KEY: 0001621141 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-35551 FILM NUMBER: 15826070 MAIL ADDRESS: STREET 1: C/O FACEBOOK, INC. STREET 2: 1601 WILLOW ROAD CITY: MENLO PARK STATE: CA ZIP: 94025 4 1 form4.xml PRIMARY DOCUMENT X0306 4 2015-04-29 0001326801 Facebook Inc FB 0001621141 Koum Jan C/O FACEBOOK, INC. 1601 WILLOW ROAD MENLO PARK CA 94025 1 Class A Common Stock 2015-02-11 5 G 0 E 3442873 0 D 57637354 I By Jan Koum, Trustee of The Butterfly Trust U/A/D 1/20/2004 Class A Common Stock 2015-02-11 5 G 0 E 3442873 0 A 3442873 I By Jan Koum and BNY Mellon Trust of Delaware, Co-Trustees of The Jan Koum Trust IV U/A/D 2/4/2015 Class A Common Stock 2015-04-29 4 J 0 3676384 80.455 D 141489 I By Jan Koum, Trustee of The Jan Koum Trust II U/A/D 8/5/2014 Class A Common Stock 2015-04-29 4 J 0 3676384 80.455 A 61313738 I By Jan Koum, Trustee of The Butterfly Trust U/A/D 1/20/2004 Class A Common Stock 2015-04-29 5 G 0 E 3500000 0 D 57813738 I By Jan Koum, Trustee of The Butterfly Trust U/A/D 1/20/2004 Class A Common Stock 2015-04-29 5 G 0 E 3500000 0 A 3500000 I By Jan Koum and BNY Mellon Trust of Delaware, Co-Trustees of The Jan Koum Trust V U/A/D 4/29/2015 Class A Common Stock 141489 I By Jan Koum, Trustee of The Jan Koum Trust I U/A/D 4/29/2014 Class A Common Stock 3817873 I By Jan Koum, Trustee of The Jan Koum Trust III U/A/D 10/9/2014 On February 11, 2015, Jan Koum, Trustee of The Butterfly Trust U/A/D 1/20/2004 contributed 3,442,873 shares of Class A common stock to Jan Koum and BNY Mellon Trust of Delaware, Co-Trustees of The Jan Koum Trust IV U/A/D 2/4/2015, a grantor retained annuity trust for the benefit of the reporting holder. Shares held of record by Jan Koum, Trustee of The Butterfly Trust U/A/D 1/20/2004. Shares held of record by Jan Koum and BNY Mellon Trust of Delaware, Co-Trustees of The Jan Koum Trust IV U/A/D 2/4/2015. Represents the transfer of shares from Jan Koum, Trustee of The Jan Koum Trust II U/A/D 8/5/2014 to Jan Koum, Trustee of The Butterfly Trust U/A/D 1/20/2004. This transaction represents a substitution of assets between the trusts, and the reporting person remains the beneficial owner of all of the shares after the transfer. Shares held of record by Jan Koum, Trustee of The Jan Koum Trust II U/A/D 8/5/2014. On April 29, 2015, Jan Koum, Trustee of The Butterfly Trust U/A/D 1/20/2004 contributed 3,500,000 shares of Class A common stock to Jan Koum and BNY Mellon Trust of Delaware, Co-Trustees of The Jan Koum Trust V U/A/D 4/29/2015, a grantor retained annuity trust for the benefit of the reporting holder. Shares held of record by Jan Koum and BNY Mellon Trust of Delaware, Co-Trustees of The Jan Koum Trust V U/A/D 4/29/2015. Shares held of record by Jan Koum, Trustee of The Jan Koum Trust I U/A/D 4/29/2014. Shares held of record by Jan Koum, Trustee of The Jan Koum Trust III U/A/D 10/9/2014. /s/ Michael Johnson as attorney-in-fact for Jan Koum 2015-05-01