0001209191-18-055134.txt : 20181016 0001209191-18-055134.hdr.sgml : 20181016 20181016163644 ACCESSION NUMBER: 0001209191-18-055134 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 2 CONFORMED PERIOD OF REPORT: 20181016 FILED AS OF DATE: 20181016 DATE AS OF CHANGE: 20181016 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: DUNN JEFFREY W CENTRAL INDEX KEY: 0001035986 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38701 FILM NUMBER: 181124750 MAIL ADDRESS: STREET 1: C/O SI-BONE, INC. STREET 2: 471 EL CAMINO REAL, SUITE 101 CITY: SANTA CLARA STATE: CA ZIP: 95050 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: SI-BONE, Inc. CENTRAL INDEX KEY: 0001459839 STANDARD INDUSTRIAL CLASSIFICATION: SURGICAL & MEDICAL INSTRUMENTS & APPARATUS [3841] IRS NUMBER: 262216351 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 471 EL CAMINO REAL, SUITE 101 CITY: SANTA CLARA STATE: CA ZIP: 95050 BUSINESS PHONE: 4082070700 MAIL ADDRESS: STREET 1: 471 EL CAMINO REAL, SUITE 101 CITY: SANTA CLARA STATE: CA ZIP: 95050 FORMER COMPANY: FORMER CONFORMED NAME: SI-Bone Inc. DATE OF NAME CHANGE: 20090326 3 1 doc3.xml FORM 3 SUBMISSION X0206 3 2018-10-16 0 0001459839 SI-BONE, Inc. SIBN 0001035986 DUNN JEFFREY W C/O SI-BONE, INC. 471 EL CAMINO REAL, SUITE 101 SANTA CLARA CA 95050 1 1 0 0 Chairman, President & CEO Common Stock 33333 D Common Stock 547540 I By Trust Stock Option (right to buy) 3.42 2024-07-21 Common Stock 272753 D Stock Option (right to buy) 4.32 2025-05-25 Common Stock 101440 D Stock Option (right to buy) 4.32 2026-07-26 Common Stock 114901 D Stock Option (right to buy) 4.68 2027-03-01 Common Stock 126260 D Includes shares issuable on settlement of restricted stock units granted to Reporting Person which vest as follows, subject to the Reporting Person's continued service through each relevant vesting date: 50% will vest on the first day of the first open trading window that occurs after the one-year anniversary of the closing of the Issuer's initial public offering and 50% will vest on the first day of the first open trading window that occurs after the two-year anniversary of the closing of the Issuer's initial public offering. Each restricted stock unit represents a contingent right to receive one share of Issuer's common stock. Shares held by The Jeffrey W. Dunn Living Trust Dated May 17, 2012. The shares subject to the option are fully vested and immediately exercisable. The shares subject to the option vest in equal monthly installments over four years commencing on April 15, 2015, subject to Reporting Person's continued service through each relevant vesting date. The shares subject to this option may be exercised prior to vesting, subject to Issuer's right to repurchase. The shares subject to the option vest in equal monthly installments over four years commencing on June 2, 2016, subject to Reporting Person's continued service through each relevant vesting date. The shares subject to this option may be exercised prior to vesting, subject to Issuer's right to repurchase. The shares subject to the option vest in equal monthly installments over four years commencing on September 6, 2017, subject to Reporting Person's continued service through each relevant vesting date. The shares subject to this option may be exercised prior to vesting, subject to Issuer's right to repurchase. Exhibit 24 - Power of Attorney /s/ Michael A. Pisetsky, Attorney-in-Fact for Jeffrey W. Dunn 2018-10-16 EX-24 2 attachment1.htm EX-24 DOCUMENT

POWER OF ATTORNEY
Know all by these presents, that the undersigned hereby constitutes and appoints
each of LAURA A. FRANCIS, MICHAEL A. PISETSKY, MATTHEW B. HEMINGTON and JOHN T.
MCKENNA, signing individually, the undersigned's true and lawful attorneys-in
fact and agents to:
(1)	execute for and on behalf of the undersigned, in the undersigned's capacity
as an officer, director or beneficial owner of more than 10% of a registered
class of securities of SI-BONE, INC. (the "Company"), Forms 3, 4 and 5
(including any amendments thereto) in accordance with Section 16(a) of the
Securities Exchange Act of 1934, as amended (the "Exchange Act") and the rules
thereunder and a Form ID, Uniform Application for Access Codes to File on EDGAR;

(2)	do and perform any and all acts for and on behalf of the undersigned that
may be necessary or desirable to execute such Forms 3, 4 or 5 or Form ID
(including any amendments thereto) and timely file such forms with the United
States Securities and Exchange Commission and any stock exchange or similar
authority; and
(3)	take any other action of any nature whatsoever in connection with the
foregoing which, in the opinion of such attorney-in-fact, may be of benefit, in
the best interest of, or legally required by, the undersigned, it being
understood that the documents executed by such attorney-in-fact on behalf of the
undersigned pursuant to this Power of Attorney shall be in such form and shall
contain such terms and conditions as such attorney-in-fact may approve in such
attorney-in-fact's discretion.
The undersigned hereby grants to each such attorney-in-fact full power and
authority to do and perform any and every act and thing whatsoever requisite,
necessary or proper to be done in the exercise of any of the rights and powers
herein granted, as fully to all intents and purposes as the undersigned might or
could do if personally present, with full power of substitution or revocation,
hereby ratifying and confirming all that such attorney-in-fact, or such
attorney-in-fact's substitute or substitutes, shall lawfully do or cause to be
done by virtue of this power of attorney and the rights and powers herein
granted. The undersigned acknowledges that the foregoing attorneys-in-fact, in
serving in such capacity at the request of the undersigned, are not assuming,
nor is the Company assuming, any of the undersigned's responsibilities to comply
with Section 16 of the Exchange Act.
This Power of Attorney shall remain in full force and effect until the earliest
to occur of (a) the undersigned is no longer required to file Forms 3, 4 and 5
with respect to the undersigned's holdings of and transactions in securities
issued by the Company, (b) revocation by the undersigned in a signed writing
delivered to the foregoing attorneys-in-fact or (c) as to any attorney-in-fact
individually, until such attorney-in-fact is no longer employed by the Company
or Cooley LLP.
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be
executed as of October 16, 2018.

/s/ Jeffrey W. Dunn
Jeffrey W. Dunn