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