0001104659-21-150711.txt : 20211216 0001104659-21-150711.hdr.sgml : 20211216 20211216203722 ACCESSION NUMBER: 0001104659-21-150711 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20211214 FILED AS OF DATE: 20211216 DATE AS OF CHANGE: 20211216 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: 211499297 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: CA FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 750 MENLO AVE. #200 CITY: MENLO PARK STATE: CA ZIP: 94025 BUSINESS PHONE: (888)276-6888 MAIL ADDRESS: STREET 1: 750 MENLO AVE. #200 CITY: MENLO PARK STATE: CA ZIP: 94025 4 1 tm2135733d1_4.xml OWNERSHIP DOCUMENT X0306 4 2021-12-14 0 0001787740 Tivic Health Systems, Inc. TIVC 0001418947 Bolton Sheryle 750 MENLO AVENUE SUITE 200 MENLO PARK CA 94025 1 0 0 0 Employee Stock Option (Right to Buy) 4.59 2021-12-14 4 A 0 18000 0 A 2031-12-13 Common Stock 18000 18000 D The option will vest one year from the grant date. /s/ Briana Benz, attorney-in-fact 2021-12-16