0000899243-23-015784.txt : 20230616 0000899243-23-015784.hdr.sgml : 20230616 20230616173007 ACCESSION NUMBER: 0000899243-23-015784 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20230614 FILED AS OF DATE: 20230616 DATE AS OF CHANGE: 20230616 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Bolton Sheryle CENTRAL INDEX KEY: 0001418947 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-41052 FILM NUMBER: 231022429 MAIL ADDRESS: STREET 1: 55 ALMADEN BLVD CITY: SAN JOSE STATE: CA ZIP: 95113 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Tivic Health Systems, Inc. CENTRAL INDEX KEY: 0001787740 STANDARD INDUSTRIAL CLASSIFICATION: ELECTROMEDICAL & ELECTROTHERAPEUTIC APPARATUS [3845] IRS NUMBER: 814016391 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 25821 INDUSTRIAL BLVD., SUITE 100 CITY: HAYWARD STATE: CA ZIP: 94545 BUSINESS PHONE: (888)276-6888 MAIL ADDRESS: STREET 1: 25821 INDUSTRIAL BLVD., SUITE 100 CITY: HAYWARD STATE: CA ZIP: 94545 4 1 doc4.xml FORM 4 SUBMISSION X0407 4 2023-06-14 0 0001787740 Tivic Health Systems, Inc. TIVC 0001418947 Bolton Sheryle 25821 INDUSTRIAL BLVD., SUITE 100 HAYWARD CA 94545 1 0 0 0 0 Employee Stock Option (Right to Buy) 0.09 2023-06-14 4 A 0 25000 0.00 A 2033-06-13 Common Stock 25000 25000 D The option vests as follows: (i) 50% on the first anniversary of the grant date, (ii) 25% on the second anniversary of the grant date, and (iii) 25% on the third anniversary of the grant date. /s/ Jennifer Ernst, attorney-in- 2023-06-16