0001104659-22-073073.txt : 20220621 0001104659-22-073073.hdr.sgml : 20220621 20220621172447 ACCESSION NUMBER: 0001104659-22-073073 CONFORMED SUBMISSION TYPE: 4/A PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20220614 FILED AS OF DATE: 20220621 DATE AS OF CHANGE: 20220621 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Bolton Sheryle CENTRAL INDEX KEY: 0001418947 FILING VALUES: FORM TYPE: 4/A SEC ACT: 1934 Act SEC FILE NUMBER: 001-41052 FILM NUMBER: 221029150 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: 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/A 1 tm2218957-3_4aseq1.xml OWNERSHIP DOCUMENT X0306 4/A 2022-06-14 2022-06-16 0 0001787740 Tivic Health Systems, Inc. TIVC 0001418947 Bolton Sheryle 25821 INDUSTRIAL BLVD., SUITE 100 HAYWARD CA 94545 1 0 0 0 Employee Stock Option (Right to Buy) 1.75 2022-06-14 4 A 0 40000 0 A 2032-06-13 Common Stock 40000 40000 D This Amendment No. 1 ("Form 4/A") to the Form 4 filed by the reporting person on June 16, 2022 (the "Original Form 4") is being filed to correct an administrative error, resulting in the incorrect versting schedule being included for the option. As reflected in this Form 4/A, 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-fact 2022-06-21