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