FORM 4 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP 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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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). |
1. Name and Address of Reporting Person*
(Street)
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2. Issuer Name and Ticker or Trading Symbol
Facebook Inc [ FB ] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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3. Date of Earliest Transaction
(Month/Day/Year) 10/30/2014 | ||||||||||||||||||||||||||
4. If Amendment, Date of Original Filed
(Month/Day/Year) |
6. Individual or Joint/Group Filing (Check Applicable Line)
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned | ||||||||||
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1. Title of Security (Instr. 3) | 2. Transaction Date (Month/Day/Year) | 2A. Deemed Execution Date, if any (Month/Day/Year) | 3. Transaction Code (Instr. 8) | 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) | 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) | 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 7. Nature of Indirect Beneficial Ownership (Instr. 4) | |||
Code | V | Amount | (A) or (D) | Price | ||||||
Class A Common Stock | 10/30/2014 | G | V | 3,817,873 | D | $0 | 57,403,843 | I | By Jan Koum, Trustee Of The Butterfly Trust U/A/D 1/20/2004(1) | |
Class A Common Stock | 10/30/2014 | G | V | 3,817,873 | A | $0 | 3,817,873 | I | Jan Koum, Trustee of The Jan Koum Trust III U/A/D 10/9/2014(2) | |
Class A Common Stock | 10/30/2014 | G(3) | V | 7,500,000 | D | $0 | 61,221,716 | I | By Jan Koum, Trustee Of The Butterfly Trust U/A/D 1/20/2004(1) | |
Class A Common Stock | 3,817,873 | I | By Jan Koum, Trustee Of The Jan Koum Trust I U/A/D 4/29/2014(4) | |||||||
Class A Common Stock | 3,817,873 | I | By Jan Koum, Trustee Of The Jan Koum Trust II U/A/D 8/5/2014(5) |
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||||||||||
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1. Title of Derivative Security (Instr. 3) | 2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) | 6. Date Exercisable and Expiration Date (Month/Day/Year) | 7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4) | 8. Price of Derivative Security (Instr. 5) | 9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) | 10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 11. Nature of Indirect Beneficial Ownership (Instr. 4) | ||||
Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Explanation of Responses: |
1. Shares held of record by Jan Koum, Trustee of The Butterfly Trust U/A/D 1/20/2004. |
2. Shares held of record by Jan Koum, Trustee of the Jan Koum Trust III U/A/D 10/9/2014. |
3. Represents shares of Class A Common Stock that were donated as a gift to Silicon Valley Community Foundation ("SVCF"). The reporting person does not exercise voting or investment control, directly or indirectly, over SVCF or any of its affiliates, or over the donated shares following this transfer. |
4. Shares held of record by Jan Koum, Trustee of the Jan Koum Trust I U/A/D 4/29/2014. |
5. Shares held of record by Jan Koum, Trustee of The Jan Koum Trust II U/A/D 8/5/2014. |
/s/ Michael Johnson, as attorney-in-fact for Jan Koum | 10/31/2014 | |
** 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 4 (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. |