1. Title of Derivative Security (Instr. 4) |
2. Date Exercisable and Expiration Date (Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) |
4. Conversion or Exercise Price of Derivative Security |
5. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 5) |
6. Nature of Indirect Beneficial Ownership (Instr. 5) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
Series B Preferred Stock
|
Â
(1)
|
Â
(1)
|
Common Stock
|
557,617
|
$
(1)
|
D
|
Â
|
Series C Preferred Stock
|
Â
(2)
|
Â
(2)
|
Common Stock
|
178,571
|
$
(2)
|
D
|
Â
|
Series D Preferred Stock
|
Â
(3)
|
Â
(3)
|
Common Stock
|
1,176,089
|
$
(3)
|
D
|
Â
|
Series D Preferred Stock Warrant (right to buy)
|
Â
(4)
|
Â
(4)
|
Series D Preferred Stock
|
208,333
(4)
|
$
(4)
|
D
|
Â
|
Series D Preferred Stock Warrant (right to buy)
|
Â
(5)
|
Â
(5)
|
Series D Preferred Stock
|
208,333
(5)
|
$
(5)
|
D
|
Â
|
Series D Preferred Stock Warrant (right to buy)
|
Â
(6)
|
Â
(6)
|
Series D Preferred Stock
|
100,000
(6)
|
$
(6)
|
D
|
Â
|
Series D Preferred Stock Warrant (right to buy)
|
Â
(7)
|
Â
(7)
|
Series D Preferred Stock
|
66,666
(7)
|
$
(7)
|
D
|
Â
|
* |
If the form is filed by more than one reporting person, see Instruction 5(b)(v). |
** |
Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). |
(1) |
The Series B Preferred Stock is convertible into Common Stock on a two-for-one basis into the number of shares of Common Stock as shown in column 3 at any time at the holder's election, and automatically upon the closing of the Issuer's initial public offering, and has no expiration date. |
(2) |
The Series C Preferred Stock is convertible into Common Stock on a two-for-one basis into the number of shares of Common Stock as shown in column 3 at any time at the holder's election, and automatically upon the closing of the Issuer's initial public offering, and has no expiration date. |
(3) |
The Series D Preferred Stock is convertible into Common Stock on a two-for-one basis into the number of shares of Common Stock as shown in column 3 at any time at the holder's election, and automatically upon the closing of the Issuer's initial public offering, and has no expiration date. |
(4) |
The Series D Preferred Stock Warrants are exercisable for such shares of Series D Preferred Stock at an exercise price of $6.00 per share. Upon the closing of the Issuer's initial public offering, the Warrants will automatically become exercisable for 104,166 shares of Common Stock at an exercise price of $12.00 per share. The Warrants are exercisable at any time at the holder's election prior to the earlier of December 31, 2016 or the occurrence of a merger, consolidation or sale of substantially all of the assets of the Issuer. |
(5) |
The Series D Preferred Stock Warrants are exercisable for such shares of Series D Preferred Stock at an exercise price of $6.00 per share. Upon the closing of the Issuer's initial public offering, the Warrants will automatically become exercisable for 104,166 shares of Common Stock at an exercise price of $12.00 per share. The Warrants are exercisable at any time at the holder's election prior to the earlier of December 31, 2016 or the occurrence of a merger, consolidation or sale of substantially all of the assets of the Issuer. |
(6) |
The Series D Preferred Stock Warrants are exercisable for such shares of Series D Preferred Stock at an exercise price of $6.00 per share. Upon the closing of the Issuer's initial public offering, the Warrants will automatically become exercisable for 50,000 shares of Common Stock at an exercise price of $12.00 per share. The Warrants are exercisable at any time at the holder's election prior to the earlier of December 31, 2016 or the occurrence of a merger, consolidation or sale of substantially all of the assets of the Issuer. |
(7) |
The Series D Preferred Stock Warrants are exercisable for such shares of Series D Preferred Stock at an exercise price of $6.00 per share. Upon the closing of the Issuer's initial public offering, the Warrants will automatically become exercisable for 33,333 shares of Common Stock at an exercise price of $12.00 per share. The Warrants are exercisable at any time at the holder's election prior to the earlier of December 31, 2016 or the occurrence of a merger, consolidation or sale of substantially all of the assets of the Issuer. |