SEC FORM 3

SEC Form 3

FORM 3

UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES

Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934
or Section 30(h) of the Investment Company Act of 1940

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1. Name and Address of Reporting Person^*

Thomas Robert

(Last)

(First)

(Middle)

C/O TRIVASCULAR TECHNOLOGIES, INC.

3910 BRICKWAY BLVD.

(Street)

SANTA ROSA

95403

(City)

(State)

(Zip)

2. Date of Event Requiring Statement (Month/Day/Year)
04/15/2014

3. Issuer Name and Ticker or Trading Symbol
TriVascular Technologies, Inc. [ TRIV ]

4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)

X	Director	10% Owner
	Officer (give title below)	Other (specify below)

5. If Amendment, Date of Original Filed (Month/Day/Year)

6. Individual or Joint/Group Filing (Check Applicable Line)

X	Form filed by One Reporting Person
	Form filed by More than One Reporting Person

Table I - Non-Derivative Securities Beneficially Owned
1. Title of Security (Instr. 4)	2. Amount of Securities Beneficially Owned (Instr. 4)	3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5)	4. Nature of Indirect Beneficial Ownership (Instr. 5)
Common Stock	8,276	D
Common Stock	3,278	I⁽¹⁾	By Mackenzie Marie Thomas Trust

Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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: Direct (D) or Indirect (I) (Instr. 5)	6. Nature of Indirect Beneficial Ownership (Instr. 5)
1. Title of Derivative Security (Instr. 4)	Date Exercisable	Expiration Date	Title	Amount or Number of Shares	4. Conversion or Exercise Price of Derivative Security	5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5)	6. Nature of Indirect Beneficial Ownership (Instr. 5)
Series B Preferred Stock	⁽²⁾	⁽²⁾	Common Stock	11,537	⁽²⁾	D
Series C Preferred Stock	⁽³⁾	⁽³⁾	Common Stock	17,725	⁽³⁾	D
Series D Preferred Stock	⁽⁴⁾	⁽⁴⁾	Common Stock	41,453	⁽⁴⁾	D
Series E Preferred Stock	⁽⁴⁾	⁽⁴⁾	Common Stock	7,847	⁽⁴⁾	D
Series D Preferred Warrants	⁽⁵⁾	02/02/2019	Common Stock	6,326	$15.8061	D
Stock Option (right to buy)	09/19/2010⁽⁸⁾	10/05/2020	Common Stock	2,824	$14.2	D
Stock Option (right to buy)	09/19/2012⁽⁷⁾	10/05/2020	Common Stock	3,337	$2.43	D
Stock Option (right to buy)	02/28/2012⁽⁸⁾	01/30/2022	Common Stock	123	$14.2	D
Stock Option (right to buy)	02/28/2012⁽⁹⁾	01/30/2022	Common Stock	862	$2.43	D
Stock Option (right to buy)	07/01/2012⁽⁶⁾	08/29/2022	Common Stock	12,324	$2.43	D
Stock Option (right to buy)	12/01/2013⁽⁶⁾	11/01/2023	Common Stock	4,929	$8.93	D

Explanation of Responses:

1. These securities are held in a trust for the benefit of the reporting person's daughter. The reporting person disclaims beneficial ownership of these securities, and the filing of this report should not be deemed an admission that the reporting person is the beneficial owner of these securities for purposes of Section 16 or for any other purpose.

2. Each share of Series B Preferred Stock is convertible into 0.03845959625192770 of a share of Common Stock without payment of further consideration and will automatically convert into 0.03845959625192770 of a share of Common Stock upon the closing of the Issuer's initial public offering without payment of further consideration. The number of securities reported in Table II is shown on a post-conversion basis. The shares have no expiration date.

3. Each share of Series C Preferred Stock is convertible into 0.03899558573514530 of a share of Common Stock without payment of further consideration and will automatically convert into 0.03899558573514530 of a share of Common Stock upon the closing of the Issuer's initial public offering without payment of further consideration. The number of securities reported in Table II is shown on a post-conversion basis. The shares have no expiration date.

4. Each share of Series D Preferred Stock and each share of Series E Preferred Stock is convertible into 0.0246487552378605 of a share of Common Stock without payment of further consideration and will automatically convert into 0.02464875523786050 of a share of Common Stock upon the closing of the Issuer's initial public offering without payment of further consideration. The number of securities reported in Table II is shown on a post-conversion basis. The shares have no expiration date.

5. Immediately.

6. 1/48th of the shares underlying the option are exercisable beginning on the one month anniversary of the vesting start date, and an additional 1/48th of the shares underlying the option become exercisable on the first day of each month anniversary thereafter.

7. 1/48th of the shares underlying the option vest and become exercisable in equal monthly installments through August 19, 2014.

8. Fully vested.

9. 1/48th of the shares underlying the option vest and become exercisable in equal monthly installments through January 30, 2016.

Remarks:

Exhibit 24 -Power of Attorney

	By: /s/ Kimberley Elting, Attorney-In-Fact Robert W. Thomas	04/15/2014
	** Signature of Reporting Person	Date
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
* 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).
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