0001104659-21-024605.txt : 20210216 0001104659-21-024605.hdr.sgml : 20210216 20210216215142 ACCESSION NUMBER: 0001104659-21-024605 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20201231 FILED AS OF DATE: 20210216 DATE AS OF CHANGE: 20210216 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Andrews Christopher CENTRAL INDEX KEY: 0001817926 FILING VALUES: FORM TYPE: 5 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39441 FILM NUMBER: 21642420 MAIL ADDRESS: STREET 1: 228 PARK AVENUE SOUTH STREET 2: SUITE 72602 CITY: NEW YORK STATE: NY ZIP: 10003 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Kubient, Inc. CENTRAL INDEX KEY: 0001729750 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-COMPUTER INTEGRATED SYSTEMS DESIGN [7373] IRS NUMBER: 821808844 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 228 PARK AVENUE STREET 2: SOUTH SUITE 72602 CITY: NEW YORK STATE: NY ZIP: 10003 BUSINESS PHONE: (800) 409-9456 MAIL ADDRESS: STREET 1: 228 PARK AVENUE STREET 2: SOUTH SUITE 72602 CITY: NEW YORK STATE: NY ZIP: 10003 5 1 tm216792d5_5.xml OWNERSHIP DOCUMENT X0306 5 2020-12-31 0 0 0 0001729750 Kubient, Inc. KBNT 0001817926 Andrews Christopher C/O KUBIENT, INC. 228 PARK AVENUE SOUTH, SUITE 72602 NEW YORK NY 10003 0 0 0 1 Former Chief Digital Officer Common Stock 2020-08-14 5 C 0 128522 A 130745 D Common Stock Purchase Warrant 5.50 2020-08-14 5 C 0 128522 A 2020-08-14 2025-08-14 Common Stock 128522 128522 D Represents the shares of common stock of Kubient, Inc. (the "Company") issued upon conversion of $480,124 of promissory notes that, upon the initial public offering of the Company, converted into 128,522 immediately-separable units composed of (i) one share of common stock, and (ii) one warrant to purchase one share of common stock at a price of $5.50 per share. Not previously reported on Form 4. Does not include 6,240 shares of common stock underlying stock options exercisable within 60 days. Also does not include 128,522 shares of common stock underlying five-year warrants issued on August 14, 2020, which are reported on Table II of this Form 5. Additionally, does not include 102,857 immediately-separable units composed of (i) one share of common stock, and (ii) one warrant to purchase one share of common stock at a price of $5.50 per share, underlying five-year warrants issued on November 6, 2019. Represents the warrants to purchase shares of common stock issued upon conversion of $480,124 of promissory notes that, upon the initial public offering of the Company, converted into 128,522 immediately-separable units composed of (i) one share of common stock, and (ii) one warrant to purchase one share of common stock at a price of $5.50 per share. /s/ Christopher Andrews 2021-02-15