0001209191-18-055158.txt : 20181016 0001209191-18-055158.hdr.sgml : 20181016 20181016165602 ACCESSION NUMBER: 0001209191-18-055158 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20181016 FILED AS OF DATE: 20181016 DATE AS OF CHANGE: 20181016 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Skyline Venture Partners V LP CENTRAL INDEX KEY: 0001419187 STATE OF INCORPORATION: DE FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38701 FILM NUMBER: 181124866 BUSINESS ADDRESS: STREET 1: 525 University Avenue STREET 2: Suite 520 CITY: Palo Alto STATE: CA ZIP: 94301 MAIL ADDRESS: STREET 1: 525 University Avenue STREET 2: Suite 520 CITY: Palo Alto STATE: CA ZIP: 94301 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Skyline Venture Management V, LLC CENTRAL INDEX KEY: 0001434887 STATE OF INCORPORATION: CA FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38701 FILM NUMBER: 181124867 BUSINESS ADDRESS: STREET 1: 525 UNIVERSITY AVENUE CITY: PALO ALTO STATE: CA ZIP: 94301 BUSINESS PHONE: 650-475-0144 MAIL ADDRESS: STREET 1: 525 UNIVERSITY AVENUE CITY: PALO ALTO STATE: CA ZIP: 94301 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Freund John Gordon CENTRAL INDEX KEY: 0001296771 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38701 FILM NUMBER: 181124868 MAIL ADDRESS: STREET 1: 125 UNIVERSITY AVE. STREET 2: C/O SKYLINE VENTURES CITY: PALO ALTO STATE: CA ZIP: 94301 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: KANEKO YASUNORI CENTRAL INDEX KEY: 0001277503 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38701 FILM NUMBER: 181124869 MAIL ADDRESS: STREET 1: 509 ROEHAMPTON CITY: HILLS BOROUGH STATE: CA ZIP: 94010 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 0001419187 Skyline Venture Partners V LP 525 UNIVERSITY AVENUE, SUITE 1350 PALO ALTO CA 94301 0 0 1 0 0001434887 Skyline Venture Management V, LLC 525 UNIVERSITY AVENUE, SUITE 1350 PALO ALTO CA 94301 0 0 1 0 0001296771 Freund John Gordon 525 UNIVERSITY AVENUE, SUITE 1350 PALO ALTO CA 94301 1 0 1 0 0001277503 KANEKO YASUNORI 525 UNIVERSITY AVENUE, SUITE 1350 PALO ALTO CA 94301 0 0 1 0 Series 4 Preferred Stock Common Stock 2213425 I By Skyline Venture Partners V, L.P. Series 5 Preferred Stock Common Stock 776678 I By Skyline Venture Partners V, L.P. Series 6 Preferred Stock Common Stock 652347 I By Skyline Venture Partners V, L.P. Series 7 Preferred Stock Common Stock 398676 I By Skyline Venture Partners V, L.P. Warrant (right to buy) 9.10 Series 5 Preferred Stock 39421 I By Skyline Venture Partners V, L.P. The Issuer's Series 4 Preferred Stock, Series 5 Preferred Stock and Series 7 Preferred Stock will automatically convert into an equal number of shares of Issuer's common stock immediately upon the closing of the Issuer's initial public offering and has no expiration date. Shares held by Skyline Venture Partners V, L.P. ("SVP V"). Skyline Venture Management V, LLC ("LLC") is the general partner of SVP V and as such may be deemed to have voting and investment power with respect to the securities of SVP V. John G. Freund, a member of the Issuer's board of directors, together with Yasunori Kaneko, are the managing directors of LLC and each may be deemed to have voting and investment power with respect to the securities held by SVP V. Dr. Freund and Mr. Kaneko disclaim beneficial ownership of such securities, except to the extent of their pecuniary interest therein. The Issuer's Series 6 Preferred Stock will automatically convert into approximately 1.05878 shares of Issuer's common stock immediately upon the closing of the Issuer's initial public offering and has no expiration date. Shares subject to the warrant are immediately exercisable. The warrant will expire in connection with the closing of the Issuer's initial public offering. Skyline Venture Partners V, L.P., By: Skyline Venture Management V, LLC, Its: General Partner, By: /s/ Kerensa Kenny, Attorney-in-Fact 2018-10-16 Skyline Venture Management V, LLC, By: /s/ Kerensa Kenny, Attorney-in-Fact 2018-10-16 John G. Freund, /s/ Kerensa Kenny, Attorney-in-Fact 2018-10-16 Yasunori Kaneko, /s/ Kerensa Kenny, Attorney-in-Fact 2018-10-16