0001104659-21-150714.txt : 20211216 0001104659-21-150714.hdr.sgml : 20211216 20211216203848 ACCESSION NUMBER: 0001104659-21-150714 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20211214 FILED AS OF DATE: 20211216 DATE AS OF CHANGE: 20211216 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: 211499301 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: CA FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 750 MENLO AVE. #200 CITY: MENLO PARK STATE: CA ZIP: 94025 BUSINESS PHONE: (888)276-6888 MAIL ADDRESS: STREET 1: 750 MENLO AVE. #200 CITY: MENLO PARK STATE: CA ZIP: 94025 4 1 tm2135733d4_4.xml OWNERSHIP DOCUMENT X0306 4 2021-12-14 0 0001787740 Tivic Health Systems, Inc. TIVC 0001891888 Gurfein Blake 750 MENLO AVENUE SUITE 200 MENLO PARK CA 94025 0 1 0 0 Chief Scientific Officer Employee Stock Option (Right to Buy) 4.59 2021-12-14 4 A 0 82500 0 A 2031-12-13 Common Stock 82500 82500 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 next 36 months. /s/ Briana Benz, attorney-in-fact 2021-12-16