FORM 3 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940 |
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1. Name and Address of Reporting Person*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 10/16/2018 |
3. Issuer Name and Ticker or Trading Symbol
SI-BONE, Inc. [ SIBN ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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5. If Amendment, Date of Original Filed
(Month/Day/Year) |
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6. Individual or Joint/Group Filing (Check Applicable Line)
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Table I - Non-Derivative Securities Beneficially Owned | |||
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1. Title of Security (Instr. 4) | 2. Amount of Securities Beneficially Owned (Instr. 4) | 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 4. Nature of Indirect Beneficial Ownership (Instr. 5) |
Common Stock | 48,218(1) | D |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
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1. Title of Derivative Security (Instr. 4) | 2. Date Exercisable and Expiration Date (Month/Day/Year) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 6. Nature of Indirect Beneficial Ownership (Instr. 5) | ||
Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Stock Option (right to buy) | (2) | 05/25/2025 | Common Stock | 189,218 | $4.32 | D | |
Stock Option (right to buy) | (3) | 03/01/2027 | Common Stock | 17,307 | $4.68 | D |
Explanation of Responses: |
1. Includes 3,703 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. |
2. The shares subject to the option vest in equal monthly installments over four years commencing on May 26, 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. |
3. 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. |
Remarks: |
Exhibit 24 - Power of Attorney |
/s/ Michael A. Pisetsky, Attorney-in-Fact for Laura A. Francis | 10/16/2018 | |
** Signature of Reporting Person | Date | |
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | ||
* If the form is filed by more than one reporting person, see Instruction 5 (b)(v). | ||
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). | ||
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. | ||
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. |