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