0001104659-16-148726.txt : 20161004
0001104659-16-148726.hdr.sgml : 20161004
20161004210851
ACCESSION NUMBER: 0001104659-16-148726
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20161004
FILED AS OF DATE: 20161004
DATE AS OF CHANGE: 20161004
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: Tabula Rasa HealthCare, Inc.
CENTRAL INDEX KEY: 0001651561
STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-BUSINESS SERVICES, NEC [7389]
IRS NUMBER: 465726437
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
BUSINESS ADDRESS:
STREET 1: 228 STRAWBRIDGE DRIVE
STREET 2: SUITE 100
CITY: MOORESTOWN
STATE: NJ
ZIP: 08057
BUSINESS PHONE: 866-648-2767
MAIL ADDRESS:
STREET 1: 228 STRAWBRIDGE DRIVE
STREET 2: SUITE 100
CITY: MOORESTOWN
STATE: NJ
ZIP: 08057
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: LUBIN DANIEL C
CENTRAL INDEX KEY: 0001335280
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-37888
FILM NUMBER: 161921243
MAIL ADDRESS:
STREET 1: RADIUS VENTURE PARTNERS II LLC
STREET 2: 400 MADISON AVE 8TH FLOOR
CITY: NEW YORK
STATE: NY
ZIP: 10017
4
1
a4.xml
4
X0306
4
2016-10-04
0
0001651561
Tabula Rasa HealthCare, Inc.
TRHC
0001335280
LUBIN DANIEL C
250 PARK AVENUE, SUITE 1102
NEW YORK
NY
10177
1
0
1
0
Common Stock
2016-10-04
4
C
0
154792
A
191603
I
By Radius Venture Partners III (Ohio), L.P.
Common Stock
2016-10-04
4
C
0
1232499
A
1525599
I
By Radius Venture Partners III QP, L.P.
Common Stock
2016-10-04
4
C
0
113027
A
139906
I
By Radius Venture Partners III, L.P.
Common Stock
2016-10-04
4
J
0
2102
0
D
189501
I
By Radius Venture Partners III (Ohio), L.P.
Common Stock
2016-10-04
4
J
0
16735
0
D
1508864
I
By Radius Venture Partners III QP, L.P.
Common Stock
2016-10-04
4
J
0
1535
0
D
138371
I
By Radius Venture Partners III, L.P.
Common Stock
5565
D
Series A-1 Preferred Stock
2016-10-04
4
C
0
29346
D
Common Stock
15127
0
I
By Radius Venture Partners III (Ohio), L.P.
Series A-1 Preferred Stock
2016-10-04
4
C
0
233659
D
Common Stock
120443
0
I
By Radius Venture Partners III QP, L.P.
Series A-1 Preferred Stock
2016-10-04
4
C
0
21428
D
Common Stock
11045
0
I
By Radius Venture Partners III, L.P.
Series B Preferred Stock
2016-10-04
4
C
0
270952
D
Common Stock
139665
0
I
By Radius Venture Partners III (Ohio), L.P.
Series B Preferred Stock
2016-10-04
4
C
0
2157390
D
Common Stock
1112056
0
I
By Radius Venture Partners III QP, L.P.
Series B Preferred Stock
2016-10-04
4
C
0
197846
D
Common Stock
101982
0
I
By Radius Venture Partners III, L.P.
These securities are held directly by Radius Venture Partners III (Ohio), L.P. and indirectly by Radius Venture Partners III, LLC, the general partner of Radius Venture Partners III (Ohio), L.P., Jordan S. Davis, managing member of Radius Venture Partners III, LLC, and Daniel C. Lubin, managing member of Radius Venture Partners III, LLC. Mr. Lubin, a director of the Issuer, and Mr. Davis share voting and dispositive power with respect to the shares held by Radius Venture Partners III (Ohio), L.P. Each of Radius Venture Partners III, LLC, Mr. Davis, and Mr. Lubin may be deemed to beneficially own such securities, and disclaims such beneficial ownership except to the extent of its or his pecuniary interest therein.
These securities are held directly by Radius Venture Partners III QP, L.P and indirectly by Radius Venture Partners III, LLC, the general partner of Radius Venture Partners III QP, L.P., Jordan S. Davis, managing member of Radius Venture Partners III, LLC, and Daniel C. Lubin, managing member of Radius Venture Partners III, LLC. Mr. Lubin, a director of the Issuer, and Mr. Davis share voting and dispositive power with respect to the shares held by Radius Venture Partners III QP, L.P. Each of Radius Venture Partners III, LLC, Mr. Davis, and Mr. Lubin may be deemed to beneficially own such securities, and disclaims such beneficial ownership except to the extent of its or his pecuniary interest therein.
These securities are held directly by Radius Venture Partners III, L.P., and indirectly by Radius Venture Partners III, LLC, the general partner of Radius Venture Partners III, L.P., Jordan S. Davis, managing member of Radius Venture Partners III, LLC, and Daniel C. Lubin, managing member of Radius Venture Partners III, LLC. Mr. Lubin, a director of the Issuer, and Mr. Davis share voting and dispositive power with respect to the shares held by Radius Venture Partners III, L.P. Each of Radius Venture Partners III, LLC, Mr. Davis, and Mr. Lubin may be deemed to beneficially own such securities, and disclaims such beneficial ownership except to the extent of its or his pecuniary interest therein.
Each share of Series A-1 Preferred Stock and Series B Preferred Stock was converted automatically into shares of the Issuer's Common Stock immediately prior to the closing of Issuer's initial public offering.
The securities did not have an expiration date.
20,372 shares of common stock were surrendered to the Issuer at the completion of Issuer's initial public offering pursuant to the letter agreement, dated as of June 30, 2014, as amended, with the Issuer.
Dr. Calvin H. Knowlton /s/ Dr. Calvin H. Knowlton, Attorney-in-Fact for Daniel Lubin
2016-10-04