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