0001144204-14-057941.txt : 20140925 0001144204-14-057941.hdr.sgml : 20140925 20140925183548 ACCESSION NUMBER: 0001144204-14-057941 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20140923 FILED AS OF DATE: 20140925 DATE AS OF CHANGE: 20140925 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: VIVEVE MEDICAL, INC. CENTRAL INDEX KEY: 0000879682 STANDARD INDUSTRIAL CLASSIFICATION: ELECTROMEDICAL & ELECTROTHERAPEUTIC APPARATUS [3845] IRS NUMBER: 043153858 STATE OF INCORPORATION: B0 FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 150 COMMERCIAL STREET CITY: SUNNYVALE STATE: CA ZIP: 94086 BUSINESS PHONE: 4085301900 MAIL ADDRESS: STREET 1: 150 COMMERCIAL STREET CITY: SUNNYVALE STATE: CA ZIP: 94086 FORMER COMPANY: FORMER CONFORMED NAME: PLC SYSTEMS INC DATE OF NAME CHANGE: 19930328 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Schwab Andrew J. CENTRAL INDEX KEY: 0001598549 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-11388 FILM NUMBER: 141121615 MAIL ADDRESS: STREET 1: C/O 5AM VENTURES, 2200 SAND HILL ROAD STREET 2: SUITE 110 CITY: MENLO PARK STATE: CA ZIP: 94025 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: 5AM CO-INVESTORS II LP CENTRAL INDEX KEY: 0001390376 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-11388 FILM NUMBER: 141121616 BUSINESS ADDRESS: STREET 1: 3000 SAND HILL RD STREET 2: STE 230 CITY: MENLO PK STATE: CA ZIP: 94025 MAIL ADDRESS: STREET 1: 3000 SAND HILL RD STREET 2: STE 230 CITY: MENLO PK STATE: CA ZIP: 94025 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: 5AM Ventures II LP CENTRAL INDEX KEY: 0001386509 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-11388 FILM NUMBER: 141121617 BUSINESS ADDRESS: STREET 1: 3000 Sand Hill Rd Bldg 4 Ste 230 CITY: Menlo Park STATE: CA ZIP: 94025 MAIL ADDRESS: STREET 1: 3000 Sand Hill Rd Bldg 4 Ste 230 CITY: Menlo Park STATE: CA ZIP: 94025 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: 5AM Partners II, LLC CENTRAL INDEX KEY: 0001555952 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-11388 FILM NUMBER: 141121618 BUSINESS ADDRESS: STREET 1: 2200 SAND HILL ROAD CITY: MENLO PARK STATE: CA ZIP: 94025 BUSINESS PHONE: 650.233.8600 MAIL ADDRESS: STREET 1: 2200 SAND HILL ROAD CITY: MENLO PARK STATE: CA ZIP: 94025 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: DIEKMAN JOHN D CENTRAL INDEX KEY: 0001240357 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-11388 FILM NUMBER: 141121619 MAIL ADDRESS: STREET 1: C/O 5 AM VENTURES STREET 2: 3000 SAND HILL RD CITY: MENLO PARK STATE: CA ZIP: 94025 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: ROCKLAGE SCOTT M CENTRAL INDEX KEY: 0001219014 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-11388 FILM NUMBER: 141121620 MAIL ADDRESS: STREET 1: 179 SANDY POND ROAD CITY: LINCOLN STATE: MA ZIP: 01773 4 1 v389921_4.xml OWNERSHIP DOCUMENT X0306 4 2014-09-23 0 0000879682 VIVEVE MEDICAL, INC. PLCSD 0001555952 5AM Partners II, LLC 2200 SAND HILL ROAD, SUITE 110 MENLO PARK CA 94025 0 0 1 0 0001386509 5AM Ventures II LP 2200 SAND HILL RD, SUITE 110 MENLO PARK CA 94025 0 0 1 0 0001390376 5AM CO-INVESTORS II LP 2200 SAND HILL RD, SUITE 110 MENLO PK CA 94025 0 0 1 0 0001598549 Schwab Andrew J. C/O 5AM VENTURES, 2200 SAND HILL ROAD SUITE 110 MENLO PARK CA 94025 0 0 1 0 0001219014 ROCKLAGE SCOTT M C/O 5AM VENTURES, 2200 SAND HILL ROAD SUITE 110 MENLO PARK CA 94025 0 0 1 0 0001240357 DIEKMAN JOHN D C/O 5 AM VENTURES, 2200 SAND HILL ROAD SUITE 110 MENLO PARK CA 94025 0 0 1 0 Common Stock 2014-09-23 4 P 0 5017677 0.53 A 6660205 I See Footnote Common Stock 2014-09-23 4 P 0 197987 0.53 A 262798 I See Footnote Shares directly beneficially owned by 5AM Ventures II, L.P. Shares directly beneficially owned by 5AM Co-Investors II, L.P. 5AM Partners II, LLC is the general partner of 5AM Ventures II, L.P. and 5AM Co-Investors II, L.P. and may be deemed to have sole voting and investment power over the shares beneficially owned by 5AM Ventures II, L.P. and 5AM Co-Investors II, L.P. Dr. John Diekman, Andrew Schwab and Dr. Scott Rocklage, the managing members of 5AM Partners II, LLC, and Mark Colella, an assignee of 5AM Partners II, LLC, may be deemed to have shared voting and investment power over the shares beneficially owned by 5AM Ventures II, L.P. and 5AM Co-Investors II, L.P. Each of 5AM Partners II, LLC, Dr. Diekman, Mr. Schwab, Dr. Rocklage and Mr. Colella disclaim beneficial ownership of such shares except to the extent of its or his pecuniary interest therein. Includes 933,544 shares issued upon conversion of a convertible promissory note issued by Viveve, Inc. in aggregate principal and interest amount of $494,778.44 at a conversion price of $0.53 per share. Includes 36,836 shares issued upon conversion of a convertible promissory note issue by Viveve, Inc. in aggregate principal and interest amount of $19,522.93 at a conversion price of $0.53 per share. /s/ Andrew J.Schwab, Managing Member, 5AM Partners II, LLC 2014-09-25 /s/ Andrew J.Schwab, Managing Member, 5AM Ventures II, L.P. 2014-09-25 /s/ Andrew J.Schwab, Managing Member, 5AM Co-Investors II, L.P. 2014-09-25 /s/ Andrw Schwab 2014-09-25 /s/ Dr. Scott Rocklage 2014-09-25 /s/ Dr. John D. Diekman 2014-09-25