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*
Pavey Robert

(Last) (First) (Middle)
C/O PEREGRINE SEMICONDUCTOR CORPORATION
9380 CARROLL PARK DRIVE

(Street)
SAN DIEGO CA 92121

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
08/07/2012
3. Issuer Name and Ticker or Trading Symbol
PEREGRINE SEMICONDUCTOR CORP [ PSMI ]
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)
08/07/2012
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 178,349 I (2) Morgenthaler Partners VI, L.P.
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
Series A1 Preferred Stock (1) (1) Common Stock 1,512,031 (1) I (2) Morgenthaler Partners VI, L.P.
Series B1 Preferred Stock (1) (1) Common Stock 413,529 (1) I (2) Morgenthaler Partners VI, L.P.
Series C1 Preferred Stock (1) (1) Common Stock 1,263,802 (1) I (2) Morgenthaler Partners VI, L.P.
Series D1 Preferred Stock (1) (1) Common Stock 183,302 (1) I (2) Morgenthaler Partners VI, L.P.
Explanation of Responses:
1. Each share of Series A1 Preferred Stock, Series B1 Preferred Stock, Series C1 Preferred Stock, and Series D1 Preferred Stock will automatically convert into one share of common stock upon the closing of the Issuer's initial public offering, and has no expiration date.
2. Morgenthaler Management Partners VI, L.L.C. is the general partner of Morgenthaler Partners VI, L.P. Robert D. Pavey, a member of Morgenthaler Management Partners VI, L.L.C., disclaims beneficial ownership of the reported securities except to the extent of his pecuniary interest therein.
/s/ Jay Biskupski as Attorney-in-fact for Robert D. Pavey 08/08/2012
** 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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