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