0001192482-16-000723.txt : 20161005 0001192482-16-000723.hdr.sgml : 20161005 20161005162615 ACCESSION NUMBER: 0001192482-16-000723 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20161004 FILED AS OF DATE: 20161005 DATE AS OF CHANGE: 20161005 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Tabula Rasa HealthCare, Inc. CENTRAL INDEX KEY: 0001651561 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-BUSINESS SERVICES, NEC [7389] IRS NUMBER: 465726437 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 228 STRAWBRIDGE DRIVE STREET 2: SUITE 100 CITY: MOORESTOWN STATE: NJ ZIP: 08057 BUSINESS PHONE: 866-648-2767 MAIL ADDRESS: STREET 1: 228 STRAWBRIDGE DRIVE STREET 2: SUITE 100 CITY: MOORESTOWN STATE: NJ ZIP: 08057 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: GAUSLING MICHAEL J CENTRAL INDEX KEY: 0001125761 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-37888 FILM NUMBER: 161922729 MAIL ADDRESS: STREET 1: 150 WEBSTER STREET CITY: BETHLEHEM STATE: PA ZIP: 18015 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Arnson Eric R CENTRAL INDEX KEY: 0001685942 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-37888 FILM NUMBER: 161922730 MAIL ADDRESS: STREET 1: 205 WEBSTER STREET CITY: BETHLEHEM STATE: PA ZIP: 18015 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: BRESSNER GLEN R CENTRAL INDEX KEY: 0000902959 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-37888 FILM NUMBER: 161922731 MAIL ADDRESS: STREET 1: 720 PENNSYLAVANIA DR CITY: EXTON STATE: PA ZIP: 19341 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Originate Growth GP, LLC CENTRAL INDEX KEY: 0001685914 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-37888 FILM NUMBER: 161922732 BUSINESS ADDRESS: STREET 1: 205 WEBSTER STREET CITY: BETHLEHEM STATE: PA ZIP: 18015 BUSINESS PHONE: (610) 866-5588 MAIL ADDRESS: STREET 1: 205 WEBSTER STREET CITY: BETHLEHEM STATE: PA ZIP: 18015 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: ORIGINATE GROWTH FUND 1A LP CENTRAL INDEX KEY: 0001384604 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-37888 FILM NUMBER: 161922733 BUSINESS ADDRESS: STREET 1: C/O ORIGINATE GROWTH FUND GP LLC STREET 2: 205 WEBSTER STREET CITY: BETHLEHEM STATE: PA ZIP: 18015 BUSINESS PHONE: 6108665588 MAIL ADDRESS: STREET 1: C/O ORIGINATE GROWTH FUND GP LLC STREET 2: 205 WEBSTER STREET CITY: BETHLEHEM STATE: PA ZIP: 18015 4 1 edgar.xml PRIMARY DOCUMENT X0306 4 2016-10-04 0001651561 Tabula Rasa HealthCare, Inc. TRHC 0001384604 ORIGINATE GROWTH FUND 1A LP 205 WEBSTER STREET BETHLEHEM PA 18015 0 0 1 0 0001685914 Originate Growth GP, LLC 205 WEBSTER STREET BETHLEHEM PA 18015 0 0 1 0 0000902959 BRESSNER GLEN R 205 WEBSTER STREET BETHLEHEM PA 18015 1 0 1 0 0001685942 Arnson Eric R 205 WEBSTER STREET BETHLEHEM PA 18015 0 0 1 0 0001125761 GAUSLING MICHAEL J 205 WEBSTER STREET BETHLEHEM PA 18015 0 0 1 0 Common Stock 2016-10-04 4 C 0 472560 A 510218 D Common Stock 2016-10-04 4 C 0 302659 A 812877 D Common Stock 2016-10-04 4 C 0 53912 A 866789 D Series A Preferred Stock 2016-10-04 4 C 0 916766 0 D Common Stock 472560 0 D Series A-1 Preferred Stock 2016-10-04 4 C 0 587158 0 D Common Stock 302659 0 D Series B Preferred Stock 2016-10-04 4 C 0 104589 0 D Common Stock 53912 0 D Originate Growth Fund #1A, L.P. ("Originate #1A"), Originate #1A was the record holder of 916,766 shares of Series A Preferred Stock, which automatically converted into 472,560 shares of common stock upon the closing of the Issuer's initial public offering. Originate #1A was the record holder of 587,158 shares of Series A-1 Preferred Stock, which automatically converted into 302,659 shares of common stock upon the closing of the Issuer's initial public offering. Originate #1A was the record holder of 104,589 shares of Series B Preferred Stock, which automatically converted into 53,912 shares of common stock upon the closing of the Issuer's initial public offering. This report is filed jointly by Originate #1A, Originate Growth GP, LLC ("Originate GP"), Glen Bressner ("Bressner"), Eric Arnson ("Arnson"), and Michael Gausling ("Gausling"). The shares are held by Originate #1A. The general partner of Originate #1A is Originate GP, a limited liability company. The members of Originate GP are Bressner, Arnson, and Gausling. The members of Originate GP share voting and dispositive power over the shares held by Originate #1A. Each of these individuals disclaims beneficial ownership of such shares, except to the extent of his pecuniary interest. All series of Preferred Stock automatically converted into Tabula Rasa HealthCare, Inc. (the "Issuer") common stock immediately prior to the closing of the initial public offering and have no expiration date. Originate Growth Fund #1A, L.P.; By: Originate Growth GP, LLC; By: /s/ Glen Bressner, Managing Partner 2016-10-04 Originate Growth GP, LLC; By: /s/ Glen Bressner, Managing Partner 2016-10-04 /s/ Glen Bressner 2016-10-04 /s/ Eric Arnson 2016-10-04 /s/ Michael Gausling 2016-10-04