0001104659-22-014166.txt : 20220208 0001104659-22-014166.hdr.sgml : 20220208 20220208173419 ACCESSION NUMBER: 0001104659-22-014166 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20220204 FILED AS OF DATE: 20220208 DATE AS OF CHANGE: 20220208 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Ernst Jennifer CENTRAL INDEX KEY: 0001889915 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-41052 FILM NUMBER: 22602982 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: 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 tm225821d2_4.xml OWNERSHIP DOCUMENT X0306 4 2022-02-04 0 0001787740 Tivic Health Systems, Inc. TIVC 0001889915 Ernst Jennifer 750 MENLO AVENUE SUITE 200 MENLO PARK CA 94025 1 1 1 0 Chief Executive Officer Employee Stock Option (Right to Buy) 1.83 2022-02-04 4 A 0 200000 0 A 2027-02-03 Common Stock 200000 200000 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 2022-02-08