0001127602-15-024513.txt : 20150807 0001127602-15-024513.hdr.sgml : 20150807 20150807183141 ACCESSION NUMBER: 0001127602-15-024513 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20150805 FILED AS OF DATE: 20150807 DATE AS OF CHANGE: 20150807 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: 151038814 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 2015-08-05 0001326801 Facebook Inc FB 0001621141 Koum Jan C/O FACEBOOK, INC. 1601 WILLOW ROAD MENLO PARK CA 94025 1 Class A Common Stock 2015-08-05 5 G 0 E 3500000 0 D 54313738 I By Jan Koum, Trustee of The Butterfly Trust U/A/D 1/20/2004 Class A Common Stock 2015-08-05 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 VI U/A/D 8/5/2015 Class A Common Stock 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 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 141489 I By Jan Koum, Trustee of The Jan Koum Trust II U/A/D 8/5/2014 Class A Common Stock 3817873 I By Jan Koum, Trustee of The Jan Koum Trust III U/A/D 10/9/2014 On August 5, 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 VI U/A/D 8/5/2015, 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 VI U/A/D 8/5/2015 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. 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 II U/A/D 8/5/2014. 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 2015-08-07