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*
(Street)
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2. Issuer Name and Ticker or Trading Symbol
TriVascular Technologies, Inc. [ TRIV ] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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3. Date of Earliest Transaction
(Month/Day/Year) 04/22/2014 | ||||||||||||||||||||||||||
4. If Amendment, Date of Original Filed
(Month/Day/Year) |
6. Individual or Joint/Group Filing (Check Applicable Line)
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned | ||||||||||
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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 | 04/22/2014 | P | 583,333 | A | $12 | 583,333 | I | See Note 1(1) | ||
Common Stock | 04/22/2014 | C | 797,208 | A | $0 | 1,380,541 | I | See Note 1(1) | ||
Common Stock | 04/22/2014 | C | 383,249 | A | $0 | 1,763,790 | I | See Note 1(1) | ||
Common Stock | 04/22/2014 | C | 531,758 | A | $0 | 2,295,548 | I | See Note 1(1) | ||
Common Stock | 04/22/2014 | C | 1,236,487 | A | $0 | 3,532,035 | I | See Note 1(1) | ||
Common Stock | 04/22/2014 | C | 411,234 | A | $0 | 3,943,269 | I | See Note 1(1) |
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||||||||||
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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 A Preferred Stock | (2) | 04/22/2014 | C | 797,208 | (2) | (2) | Common Stock | 797,208 | (2) | 0 | I | See Note 1(1) | |||
Series B Preferred Stock | (2) | 04/22/2014 | C | 383,249 | (2) | (2) | Common Stock | 383,249 | (2) | 0 | I | See Note 1(1) | |||
Series C Preferred Stock | (3) | 04/22/2014 | C | 531,758 | (3) | (3) | Common Stock | 531,758 | (3) | 0 | I | See Note 1(1) | |||
Series D Preferred Stock | (4) | 04/22/2014 | C | 1,236,487 | (4) | (4) | Common Stock | 1,236,487 | (4) | 0 | I | See Note 1(1) | |||
Series E Preferred Stock | (4) | 11/01/2013 | A | 411,234 | (4) | (4) | Common Stock | 411,234 | (4) | 411,234 | I | See Note 1(1) | |||
Series E Preferred Stock | (4) | 04/22/2014 | C | 411,234 | (4) | (4) | Common Stock | 411,234 | (4) | 0 | I | See Note 1(1) | |||
Warrant to Purchase Series D Preferred Stock (right to buy) | (4) | 04/22/2014 | C | 55,831(4) | 02/02/2012 | 02/02/2019 | Series D Preferred Stock | 55,831 | $15.8061 | 0 | I | See Note 1(1) | |||
Warrant to Purchase Common Stock (right to buy) | $15.8061 | 04/22/2014 | C | 55,831(4) | 02/02/2012 | 02/02/2019 | Common Stock | 55,831 | $0 | 55,831 | I | See Note 1(1) |
Explanation of Responses: |
1. The Reporting Person is a manager of NEA 12 GP, LLC, which is the sole general partner of NEA Partners 12, Limited Partnership ("NEA Partners 12"). NEA Partners 12 is the sole general partner of New Enterprise Associates 12, Limited Partnership ("NEA 12"), the direct beneficial owner of the securities. The Reporting Person disclaims beneficial ownership within the meaning of Section 16 of the Securities Exchange Act of 1934, as amended, or otherwise of such portion of the securities held by NEA 12 in which the Reporting Person has no pecuniary interest. |
2. Each share of Series A Preferred Stock and each share of Series B Preferred Stock converted into 0.03845959625192770 of a share of Common Stock upon the closing of the Issuer's initial public offering without payment of further consideration. The number of securities reported in Table II is shown on an as converted basis. The shares have no expiration date. |
3. Each share of Series C Preferred Stock converted in to 0.03899558573514530 of a share of Common Stock upon the closing of the Issuer's initial public offering without payment of further consideration. The number of securities reported in Table II is shown on an as converted basis. The shares have no expiration date. |
4. Each share of Series D Preferred Stock and each share of Series E Preferred Stock converted into 0.02464875523786050 of a share of Common Stock upon the closing of the Issuer's initial public offering without payment of further consideration. The number of securities reported in Table II is shown on an as converted basis. The shares have no expiration date. |
/s/ Sasha Keough, attorney-in-fact | 04/24/2014 | |
** 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). | ||
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. | ||
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. |