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
OMB APPROVAL
OMB Number: 3235-0104
Estimated average burden
hours per response: 0.5
1. Name and Address of Reporting Person*
SIMINOFF DAVID E

(Last) (First) (Middle)
400 LOGUE AVENUE

(Street)
MOUNTAIN VIEW CA 94043

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
03/06/2014
3. Issuer Name and Ticker or Trading Symbol
COUPONS.com Inc [ COUP ]
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 164,329 I by David E. Siminoff, Trustee of the D&E Living Trust, u/t/a 10/25/96
Common Stock 7,568 I by Child
Common Stock 7,568 I by Child
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)
Date Exercisable Expiration Date Title Amount or Number of Shares
Employee Stock Option (right to buy) (1) 01/13/2021 Common Stock 58,333 $3.675 D
Employee Stock Option (right to buy) (2) 02/06/2022 Common Stock 48,597 $5.325 D
Explanation of Responses:
1. Subject to the Reporting Person's continued service to the Issuer, 25% of the shares underlying the options vested on the one-year anniversary of 12/22/2010, and thereafter 1/48th of the shares vest monthly and become 100% exercisable on 12/22/2014.
2. Subject to the Reporting Person's continued service to the Issuer, 25% of the shares underlying the options vested on the one-year anniversary of 2/07/2012, and thereafter 1/48th of the shares vest monthly and become 100% exercisable on 2/07/2016.
Remarks:
By: /s/Richard Hornstein, as Power of Attorney on behalf of David E. Siminoff 03/06/2014
** 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).
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure.
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number.