0001209191-17-014104.txt : 20170223
0001209191-17-014104.hdr.sgml : 20170223
20170223213201
ACCESSION NUMBER: 0001209191-17-014104
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20170222
FILED AS OF DATE: 20170223
DATE AS OF CHANGE: 20170223
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: 17634578
MAIL ADDRESS:
STREET 1: PO BOX 81226
CITY: SEATTLE
STATE: WA
ZIP: 98108-1226
4
1
doc4.xml
FORM 4 SUBMISSION
X0306
4
2017-02-22
0
0001114995
IMPINJ INC
PI
0001184752
ALBERG TOM A
999 THIRD AVENUE
34TH FLOOR
SEATTLE
WA
98104
1
0
0
0
Common Stock
2017-02-22
4
J
0
969886
0.00
D
235551
I
See footnote
Common Stock
2017-02-22
4
J
0
105649
0.00
D
129902
I
See footnote
Common Stock
2017-02-22
4
J
0
129902
0.00
D
0
I
See footnote
Common Stock
2017-02-22
4
J
0
42151
0.00
A
77865
D
Common Stock
2017-02-22
4
J
0
31489
0.00
A
109354
D
Common Stock
2017-02-22
4
J
0
1415
0.00
A
110769
D
Common Stock
2017-02-22
4
J
0
4817
0.00
A
4817
I
By Alberg Family Investments LLC
Common Stock
2017-02-22
4
J
0
31219
0.00
A
31219
I
By Raven Trust Fund
Pro rata distribution from Madrona Venture Fund I-A, LP, of which the reporting person is a managing member.
129,902 of these shares are held by Madrona Managing Director Fund, LLC and 105,649 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.
Pro rata distribution from Madrona Venture Fund I-B, L.P., of which the reporting person is a managing member.
Represents 129,902 shares held by Madrona Managing Director Fund, LLC.
Pro rata distribution from Madrona Managing Director Fund, LLC, of which the reporting person is a managing member.
Pro rata distribution from Madrona Investment Partners, LLC, of which the reporting person is a managing member.
Shares held of record by the Alberg Family Investments LLC. Mr. Alberg shares voting and dispositive control over such shares but disclaims beneficial ownership over such shares.
Shares held of record by Raven Trust Fund. Mr. Alberg shares voting and dispositive control over such shares but disclaims beneficial ownership over such shares.
Yukio Morikubo, as Attorney in fact for Tom Alberg
2017-02-23