0001209191-18-055697.txt : 20181019
0001209191-18-055697.hdr.sgml : 20181019
20181019164804
ACCESSION NUMBER: 0001209191-18-055697
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20181019
FILED AS OF DATE: 20181019
DATE AS OF CHANGE: 20181019
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Freund John Gordon
CENTRAL INDEX KEY: 0001296771
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-38701
FILM NUMBER: 181130858
MAIL ADDRESS:
STREET 1: 125 UNIVERSITY AVE.
STREET 2: C/O SKYLINE VENTURES
CITY: PALO ALTO
STATE: CA
ZIP: 94301
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: SI-BONE, Inc.
CENTRAL INDEX KEY: 0001459839
STANDARD INDUSTRIAL CLASSIFICATION: SURGICAL & MEDICAL INSTRUMENTS & APPARATUS [3841]
IRS NUMBER: 262216351
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
BUSINESS ADDRESS:
STREET 1: 471 EL CAMINO REAL, SUITE 101
CITY: SANTA CLARA
STATE: CA
ZIP: 95050
BUSINESS PHONE: 4082070700
MAIL ADDRESS:
STREET 1: 471 EL CAMINO REAL, SUITE 101
CITY: SANTA CLARA
STATE: CA
ZIP: 95050
FORMER COMPANY:
FORMER CONFORMED NAME: SI-Bone Inc.
DATE OF NAME CHANGE: 20090326
4
1
doc4.xml
FORM 4 SUBMISSION
X0306
4
2018-10-19
0
0001459839
SI-BONE, Inc.
SIBN
0001296771
Freund John Gordon
C/O SKYLINE VENTURES
525 UNIVERSITY AVENUE, SUITE 1350
PALO ALTO
CA
94301
1
0
1
0
Common Stock
2018-10-19
4
C
0
2213425
A
2213425
I
By Skyline Venture Partners V, L.P.
Common Stock
2018-10-19
4
C
0
792195
A
3005620
I
By Skyline Venture Partners V, L.P.
Common Stock
2018-10-19
4
C
0
690689
A
3696309
I
By Skyline Venture Partners V, L.P.
Common Stock
2018-10-19
4
C
0
398676
A
4094985
I
By Skyline Venture Partners V, L.P.
Common Stock
2018-10-19
4
P
0
325000
15.00
A
4419985
I
By Skyline Venture Partners V, L.P.
Warrant (right to buy)
9.10
2018-10-19
4
X
0
39421
0.00
D
Series 5 Preferred Stock
39421
0
I
By Skyline Venture Partners V, L.P.
Series 5 Preferred Stock
9.10
2018-10-19
4
X
0
39421
0.00
A
Common Stock
39421
816099
I
By Skyline Venture Partners V, L.P.
Series 5 Preferred Stock
2018-10-19
4
S
0
23904
15.00
D
Common Stock
23904
792195
I
By Skyline Venture Partners V, L.P.
Series 4 Preferred Stock
2018-10-19
4
C
0
2213425
D
Common Stock
2213425
0
I
By Skyline Venture Partners V, L.P.
Series 5 Preferred Stock
2018-10-19
4
C
0
792195
D
Common Stock
792195
0
I
By Skyline Venture Partners V, L.P.
Series 6 Preferred Stock
2018-10-19
4
C
0
652347
D
Common Stock
690689
0
I
By Skyline Venture Partners V, L.P.
Series 7 Preferred Stock
2018-10-19
4
C
0
398676
D
Common Stock
398676
0
I
By Skyline Venture Partners V, L.P.
The Issuer's Series 4 Preferred Stock, Series 5 Preferred Stock and Series 7 Preferred Stock automatically converted into an equal number of shares of Issuer's common stock immediately upon the closing of the Issuer's initial public offering and has no expiration date.
Shares held by Skyline Venture Partners V, L.P. ("SVP V"). Skyline Venture Management V, LLC ("LLC") is the general partner of SVP V and as such may be deemed to have voting and investment power with respect to the securities of SVP V. Dr. Freund, a member of the Issuer's board of directors, together with Yasunori Kaneko, are the managing directors of LLC and each may be deemed to have voting and investment power with respect to the securities held by SVP V. Dr. Freund disclaims beneficial ownership of such securities, except to the extent of his pecuniary interest therein.
The Issuer's Series 6 Preferred Stock automatically converted into approximately 1.05878 shares of Issuer's common stock immediately upon the closing of the Issuer's initial public offering and has no expiration date.
Shares subject to the warrant are immediately exercisable. The warrant will expire in connection with the closing of the Issuer's initial public offering.
Immediately prior to the closing of the Issuer's initial public offering, SVP V exercised a warrant to purchase 39,421 shares of Series 5 Preferred Stock at an exercise price of $9.10 per share. The exercise price was paid on a net exercise cashless basis calculated using the Issuer's initial public offering price of $15.00, resulting in the Issuer withholding 23,904 of the warrant shares to pay the exercise price and issuing SVP V the remaining 15,517 shares.
/s/ Michael A. Pisetsky, Attorney-in-Fact for John G. Freund
2018-10-19