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) 09/22/2016 |
3. Issuer Name and Ticker or Trading Symbol
Apptio Inc [ APTI ] |
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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 A Preferred Stock | (6) | (6) | Class B Common Stock(7) | 2,295,000 | (6) | I | See footnote(1) |
Series B Preferred Stock | (6) | (6) | Class B Common Stock(7) | 1,509,095 | (6) | I | See footnote(2) |
Series C Preferred Stock | (6) | (6) | Class B Common Stock(7) | 763,076 | (6) | I | See footnote(3) |
Series D Preferred Stock | (6) | (6) | Class B Common Stock(7) | 430,806 | (6) | I | See footnote(4) |
Series E Preferred Stock | (6) | (6) | Class B Common Stock(7) | 201,809 | (6) | I | See footnote(5) |
1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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Explanation of Responses: |
1. Includes 2,206,839 shares held by Madrona Venture Fund III, L.P. ("Madrona III") and 88,161 shares held by Madrona Venture Fund III-A, L.P. ("Madrona III-A"). Matthew McIlwain (who is a director of the issuer and files separate section 16(a) reports) is a Managing Director of the various entities affiliated with Madrona. Madrona Investment Partners III, L.P. is the general partner of each of Madrona III and Madrona III-A. Each of the Filing Persons disclaims beneficial ownership of the shares except to the extent of his or its pecuniary interest therein. |
2. Includes 1,451,124 shares held by Madrona III and 57,971 shares held by Madrona III-A. Each of the Filing Persons disclaims beneficial ownership of the shares except to the extent of his or its pecuniary interest therein. |
3. Includes 733,763 shares held by Madrona III and 29,313 shares held by Madrona III-A. Each of the Filing Persons disclaims beneficial ownership of the shares except to the extent of his or its pecuniary interest therein. |
4. Includes 414,257 shares held by Madrona III and 16,549 shares held by Madrona III-A. Each of the Filing Persons disclaims beneficial ownership of the shares except to the extent of his or its pecuniary interest therein. |
5. Includes 194,057 shares held by Madrona III and 7,752 shares held by Madrona III-A. Each of the Filing Persons disclaims beneficial ownership of the shares except to the extent of his or its pecuniary interest therein. |
6. These shares of Preferred Stock have no expiration date or conversion price and will automatically convert to shares of the issuer's Class B Common Stock immediately prior to the closing of the issuer's initial public offering on a 1-for-1 basis. |
7. Class B Common Stock is convertible at any time, at the holder's election, into Class A Common Stock on a 1-for-1 basis and has no expiration date. |
Remarks: |
/s/ John Morrow, as attorney-in-fact for Madrona Venture Fund III, L.P. | 09/22/2016 | |
/s/ John Morrow, as attorney-in-fact for Madrona Venture Fund III-A, L.P. | 09/22/2016 | |
/s/ John Morrow, as attorney-in-fact for Madrona Investment Partners III, L.P. | 09/22/2016 | |
** 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. |