SEC Form 4
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*
ORIGINATE GROWTH FUND 1Q LP

(Last) (First) (Middle)
205 WEBSTER STREET

(Street)
BETHLEHEM PA 18015

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
Tabula Rasa HealthCare, Inc. [ TRHC ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director X 10% Owner
Officer (give title below) Other (specify below)
3. Date of Earliest Transaction (Month/Day/Year)
10/04/2016
4. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
Form filed by One Reporting Person
X Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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
Common Stock 10/04/2016 C 1,043,510 A (1) 1,126,670 D(2)
Common Stock 10/04/2016 C 668,353 A (1) 1,795,023 D(2)
Common Stock 10/04/2016 C 119,055 A (1) 1,914,078 D(2)
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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
Series A Preferred Stock (1) 10/04/2016 C 2,024,410 (3) (3) Common Stock 1,043,510(1) $0(1) 0 D(2)
Series A-1 Preferred Stock (1) 10/04/2016 C 1,296,605 (3) (3) Common Stock 668,353(1) $0(1) 0 D(2)
Series B Preferred Stock (1) 10/04/2016 C 230,968 (3) (3) Common Stock 119,055(1) $0(1) 0 D(2)
1. Name and Address of Reporting Person*
ORIGINATE GROWTH FUND 1Q LP

(Last) (First) (Middle)
205 WEBSTER STREET

(Street)
BETHLEHEM PA 18015

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
Director X 10% Owner
Officer (give title below) Other (specify below)
1. Name and Address of Reporting Person*
Originate Growth GP, LLC

(Last) (First) (Middle)
205 WEBSTER STREET

(Street)
BETHLEHEM PA 18015

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
Director X 10% Owner
Officer (give title below) Other (specify below)
1. Name and Address of Reporting Person*
BRESSNER GLEN R

(Last) (First) (Middle)
205 WEBSTER STREET

(Street)
BETHLEHEM PA 18015

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
X Director X 10% Owner
Officer (give title below) Other (specify below)
1. Name and Address of Reporting Person*
Arnson Eric R

(Last) (First) (Middle)
205 WEBSTER STREET

(Street)
BETHLEHEM PA 18015

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
Director X 10% Owner
Officer (give title below) Other (specify below)
1. Name and Address of Reporting Person*
GAUSLING MICHAEL J

(Last) (First) (Middle)
205 WEBSTER STREET

(Street)
BETHLEHEM PA 18015

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
Director X 10% Owner
Officer (give title below) Other (specify below)
Explanation of Responses:
1. Originate Growth Fund #1Q, L.P. ("Originate #1Q") was the record holder of 2,024,410 shares of Series A Preferred Stock, which automatically converted into 1,043,510 shares of common stock upon the closing of the Issuer's initial public offering. Originate #1Q was the record holder of 1,296,605 shares of Series A-1 Preferred Stock, which automatically converted into 668,353 shares of common stock upon the closing of the Issuer's initial public offering. Originate #1Q was the record holder of 230,968 shares of Series B Preferred Stock, which automatically converted into 119,055 shares of common stock upon the closing of the Issuer's initial public offering.
2. This report is filed jointly by Originate #1Q, Originate Growth GP, LLC ("Originate GP"), Glen Bressner ("Bressner"), Eric Arnson ("Arnson"), and Michael Gausling ("Gausling"). The shares are held by Originate #1Q. The general partner of Originate #1Q is Originate GP, a limited liability company. The members of Originate GP are Bressner, Arnson, and Gausling. The members of Originate GP share voting and dispositive power over the shares held by Originate #1Q. Each of these individuals disclaims beneficial ownership of such shares, except to the extent of his pecuniary interest.
3. All series of Preferred Stock automatically converted into Tabula Rasa HealthCare, Inc. (the "Issuer") common stock immediately prior to the closing of the initial public offering and have no expiration date.
Remarks:
Originate Growth Fund #1Q, L.P.; By: Originate GP, LLC; By: /s/ Glen Bressner, Managing Partner 10/04/2016
Originate Growth GP, LLC; By: /s/ Glen Bressner, Managing Partner 10/04/2016
/s/ Glen Bressner 10/04/2016
/s/ Eric Arnson 10/04/2016
/s/ Michael Gausling 10/04/2016
** 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).
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