0001209191-18-055708.txt : 20181019 0001209191-18-055708.hdr.sgml : 20181019 20181019170115 ACCESSION NUMBER: 0001209191-18-055708 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20181019 FILED AS OF DATE: 20181019 DATE AS OF CHANGE: 20181019 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Valentine Keith CENTRAL INDEX KEY: 0001289408 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38701 FILM NUMBER: 181130966 MAIL ADDRESS: STREET 1: 7475 LUSK BLVD. CITY: SAN DIEGO STATE: CA ZIP: 92121 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 4 1 doc4.xml FORM 4 SUBMISSION X0306 4 2018-10-19 0 0001459839 SI-BONE, Inc. SIBN 0001289408 Valentine Keith C/O SI-BONE, INC. 471 EL CAMINO REAL, SUITE 101 SANTA CLARA CA 95050 1 0 0 0 Common Stock 2018-10-19 4 C 0 9966 A 31374 D Series 7 Preferred Stock 2018-10-19 4 C 0 9966 D Common Stock 9966 0 D The Issuer's Series 7 Preferred Stock automatically converted 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. /s/ Keith C. Valentine 2018-10-19