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*
Chelvey International Ltd

(Last) (First) (Middle)
C/O VICARIOUS SURGICAL INC.
78 FOURTH AVENUE

(Street)
WALTHAM MA 02451

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
Vicarious Surgical Inc. [ RBOT ]
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)
09/17/2021
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
Class A Common Stock 09/17/2021 A 10,036,850 A (1) 10,036,850 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
1. Name and Address of Reporting Person*
Chelvey International Ltd

(Last) (First) (Middle)
C/O VICARIOUS SURGICAL INC.
78 FOURTH AVENUE

(Street)
WALTHAM MA 02451

(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*
E15 Fund II, LP

(Last) (First) (Middle)
C/O VICARIOUS SURGICAL INC.
78 FOURTH AVENUE

(Street)
WALTHAM MA 02451

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
Director 10% Owner
Officer (give title below) X Other (specify below)
Sole Shareholder
1. Name and Address of Reporting Person*
Liang Philip

(Last) (First) (Middle)
C/O VICARIOUS SURGICAL INC.
78 FOURTH AVENUE

(Street)
WALTHAM MA 02451

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
Director 10% Owner
Officer (give title below) X Other (specify below)
Managing Partner
1. Name and Address of Reporting Person*
Patnaik Shrikant

(Last) (First) (Middle)
C/O VICARIOUS SURGICAL INC.
78 FOURTH AVENUE

(Street)
WALTHAM MA 02451

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
Director 10% Owner
Officer (give title below) X Other (specify below)
Principal
Explanation of Responses:
1. In connection with the closing of the transactions contemplated by the Agreement and Plan of Merger, dated as of April 15, 2021, by and among D8 Holdings Corp. ("D8"), Snowball Merger Sub, Inc., a Delaware corporation and wholly owned subsidiary of D8 ("Merger Sub"), and Vicarious Surgical Inc., a Delaware corporation ("Vicarious"), pursuant to which Merger Sub merged with and into Vicarious, with Vicarious surviving as a wholly-owned subsidiary of D8 (which changed its name to "Vicarious Surgical Inc.", the "Issuer"), these shares were received in exchange for 3,043,028 Series A3 Preferred Stock of Vicarious.
2. E15 Fund II, LP, the sole shareholder of Chelvey International Limited, may be deemed to have sole voting and dispositive power over the shares held by Chelvey International Limited. Philip Liang is the managing partner of E15 Fund II, LP and Shrikant Patnaik is a principal of E15 Fund II, LP and may be deemed to share voting and dispositive power over the shares held by Chelvey International Limited. Such persons and entities disclaim beneficial ownership of shares held by Chelvey International Limited, except to the extent of any pecuniary interest therein.
/s/ June Morris, Attorney-in-Fact 10/01/2021
** 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).
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