0001209191-16-133997.txt : 20160726 0001209191-16-133997.hdr.sgml : 20160726 20160726195450 ACCESSION NUMBER: 0001209191-16-133997 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20160726 FILED AS OF DATE: 20160726 DATE AS OF CHANGE: 20160726 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: IMPINJ INC CENTRAL INDEX KEY: 0001114995 STANDARD INDUSTRIAL CLASSIFICATION: ELECTRONIC COMPONENTS, NEC [3679] IRS NUMBER: 912041398 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 400 FAIRVIEW AVENUE NORTH STREET 2: SUITE 1200 CITY: SEATTLE STATE: WA ZIP: 98109 BUSINESS PHONE: 206-517-5300 MAIL ADDRESS: STREET 1: 400 FAIRVIEW AVENUE NORTH STREET 2: SUITE 1200 CITY: SEATTLE STATE: WA ZIP: 98109 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: ALBERG TOM A CENTRAL INDEX KEY: 0001184752 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-37824 FILM NUMBER: 161785424 MAIL ADDRESS: STREET 1: PO BOX 81226 CITY: SEATTLE STATE: WA ZIP: 98108-1226 4 1 doc4.xml FORM 4 SUBMISSION X0306 4 2016-07-26 0 0001114995 IMPINJ INC PI 0001184752 ALBERG TOM A 999 THIRD AVENUE 34TH FLOOR SEATTLE WA 98104 1 0 0 0 Common Stock 2016-07-26 2016-07-26 4 C 0 672895 0.00 A 672895 I See footnote Common Stock 2016-07-26 2016-07-26 4 C 0 515242 0.00 A 1188137 I See footnote Common Stock 2016-07-26 2016-07-26 4 X 0 37028 9.32 A 1225165 I See footnote Common Stock 2016-07-26 2016-07-26 4 F 0 24646 14.00 D 1200519 I See footnote Common Stock 2016-07-26 2016-07-26 4 P 0 35714 14.00 A 35714 D Series 1 Preferred Stock 0.00 2016-07-26 2016-07-26 4 C 0 672895 0.00 D Common Stock 672895 0 I N/A Series 2 Preferred Stock 0.00 2016-07-26 2016-07-26 4 C 0 412203 0.00 D Common Stock 412203 0 I N/A Series 2 Preferred Warrant (Right to Buy) 9.32 2016-07-26 2016-07-26 4 X 0 29623 0.00 D 2017-06-30 Common Stock 29623 0 I N/A Each share of Series 1 Preferred Stock automatically converted into one share of Common Stock immediately prior to the completion of the Issuer's initial public offering of Common Stock and had no expiration date. 72,531 of these shares are held of record by Madrona Managing Director Fund, LLC; 541,350 of these shares are held of record by Madrona Venture Fund I-A, L.P.; and 59,014 of these shares are held of record by Madrona Venture Fund I-B, L.P. Madrona Investment Partners, LLC, as the sole general partner of Madrona Venture Fund I-A, L.P. and Madrona Venture Fund I-B, L.P., may be deemed to beneficially own certain of the shares held of record by Madrona Venture Fund I-A, L.P. and Madrona Venture Fund I-B, L.P. but disclaims beneficial ownership of such shares in which it does not have an actual pecuniary interest. Tom A. Alberg, a member of the board of directors, disclaims beneficial ownership of all shares held of record by Madrona Managing Director Fund, LLC, Madrona Venture Fund I-A, L.P. and Madrona Venture Fund I-B, L.P., in which he does not have an actual pecuniary interest. By virtue of their relationship as affiliated entities who have overlapping general partners and managing directors, Madrona Managing Director Fund, LLC, Madrona Venture Fund I-A, L.P., Madrona Venture Fund I-B, L.P., Madrona Investment Partners, LLC and Mr. Alberg may be deemed to share voting and investment control of the record shares. Each share of Series 2 Preferred Stock automatically converted into 1.24996780424983 shares of Common Stock immediately prior to the completion of the Issuer's initial public offering of Common Stock and had no expiration date. 128,041 of these shares are held of record by Madrona Managing Director Fund, LLC; 955,959 of these shares are held of record by Madrona Venture Fund I-A, L.P.; and 104,137 of these shares are held of record by Madrona Venture Fund I-B, L.P. The warrant was automatically net exercised immediately prior to the completion of the Issuer's initial public offering of Common Stock. 132,030 of these shares are held of record by Madrona Managing Director Fund, LLC; 985,756 of these shares are held of record by Madrona Venture Fund I-A, L.P.; and 107,379 of these shares are held of record by Madrona Venture Fund I-B, L.P. 129,375 of these shares are held of record by Madrona Managing Director Fund, LLC; 965,923 of these shares are held of record by Madrona Venture Fund I-A, L.P.; and 105,221 of these shares are held of record by Madrona Venture Fund I-B, L.P. Yukio Morikubo as Attorney in fact for Tom Alberg 2016-07-26