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*
ALBERG TOM A

(Last) (First) (Middle)
999 THIRD AVENUE
34TH FLOOR

(Street)
SEATTLE WA 98104

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
IMPINJ INC [ PI ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director 10% Owner
Officer (give title below) Other (specify below)
3. Date of Earliest Transaction (Month/Day/Year)
07/26/2016
4. If Amendment, Date of Original Filed (Month/Day/Year)
07/26/2016
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
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 07/26/2016 07/26/2016 C(1) 672,895 A $0.00 672,895(2) I See footnote(3)
Common Stock 07/26/2016 07/26/2016 C(4) 515,236 A $0.00 1,188,131(5) I See footnote(3)
Common Stock 07/26/2016 07/26/2016 X(6) 37,026 A $7.46 1,225,157(7) I See footnote(3)
Common Stock 07/26/2016 07/26/2016 F(6) 19,720 D $14 1,205,437(8) I See footnote(3)
Common Stock 07/26/2016 07/26/2016 P 35,714 A $14 35,714 D
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 1 Preferred Stock $0.00 07/26/2016 07/26/2016 C(1) 672,895 (1) (1) Common Stock 672,895 $0.00 0 I N/A
Series 2 Preferred Stock $0.00 07/26/2016 07/26/2016 C(4) 412,203 (4) (4) Common Stock 412,203 $0.00 0 I N/A
Series 2 Preferred Warrant (Right to Buy) $9.32 07/26/2016 07/26/2016 X(6) 29,623 (4) 06/30/2017 Common Stock 29,623 $0.00 0 I N/A
Explanation of Responses:
1. 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.
2. 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.
3. 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.
4. 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.
5. 128,039 of these shares are held of record by Madrona Managing Director Fund, LLC; 955,957 of these shares are held of record by Madrona Venture Fund I-A, L.P.; and 104,135 of these shares are held of record by Madrona Venture Fund I-B, L.P.
6. The warrant was automatically net exercised immediately prior to the completion of the Issuer's initial public offering of Common Stock.
7. 132,027 of these shares are held of record by Madrona Managing Director Fund, LLC; 985,753 of these shares are held of record by Madrona Venture Fund I-A, L.P.; and 107,377 of these shares are held of record by Madrona Venture Fund I-B, L.P.
8. 129,902 of these shares are held of record by Madrona Managing Director Fund, LLC; 969,886 of these shares are held of record by Madrona Venture Fund I-A, L.P.; and 105,649 of these shares are held of record by Madrona Venture Fund I-B, L.P.
Remarks:
Yukio Morikubo as Attorney in fact for Tom Alberg 08/30/2016
** 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).
** 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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