0000899243-23-012533.txt : 20230510 0000899243-23-012533.hdr.sgml : 20230510 20230510184352 ACCESSION NUMBER: 0000899243-23-012533 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20230508 FILED AS OF DATE: 20230510 DATE AS OF CHANGE: 20230510 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Gurfein Blake CENTRAL INDEX KEY: 0001891888 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-41052 FILM NUMBER: 23908188 MAIL ADDRESS: STREET 1: 750 MENLO AVENUE STREET 2: SUITE 200 CITY: MENLO PARK STATE: CA ZIP: 94025 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Tivic Health Systems, Inc. CENTRAL INDEX KEY: 0001787740 STANDARD INDUSTRIAL CLASSIFICATION: ELECTROMEDICAL & ELECTROTHERAPEUTIC APPARATUS [3845] IRS NUMBER: 814016391 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 25821 INDUSTRIAL BLVD., SUITE 100 CITY: HAYWARD STATE: CA ZIP: 94545 BUSINESS PHONE: (888)276-6888 MAIL ADDRESS: STREET 1: 25821 INDUSTRIAL BLVD., SUITE 100 CITY: HAYWARD STATE: CA ZIP: 94545 4 1 doc4.xml FORM 4 SUBMISSION X0407 4 2023-05-08 0 0001787740 Tivic Health Systems, Inc. TIVC 0001891888 Gurfein Blake 25821 INDUSTRIAL BLVD., SUITE 100 HAYWARD CA 94545 0 1 0 0 Chief Scientific Officer 0 Employee Stock Option (Right to Buy) 0.13 2023-05-08 4 A 0 100000 0.00 A 2033-05-07 Common Stock 100000 100000 D The option vests as follows: (i) 25% one year from the grant date, and (ii) the remaining 75% in equal monthly installments over the 36 months thereafter. /s/ Jennifer Ernst, attorney-in-fact 2023-05-10