0001209191-21-066848.txt : 20211124
0001209191-21-066848.hdr.sgml : 20211124
20211124182250
ACCESSION NUMBER: 0001209191-21-066848
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20210707
FILED AS OF DATE: 20211124
DATE AS OF CHANGE: 20211124
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Palihapitiya Chamath
CENTRAL INDEX KEY: 0001715450
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-39252
FILM NUMBER: 211448408
MAIL ADDRESS:
STREET 1: C/O SOCIAL CAPITAL
STREET 2: 317 UNIVERSITY AVE, SUITE 200
CITY: PALO ALTO
STATE: CA
ZIP: 94301
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: ChaChaCha SPAC C, LLC
CENTRAL INDEX KEY: 0001806665
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-39252
FILM NUMBER: 211448407
BUSINESS ADDRESS:
STREET 1: 120 HAWTHORNE AVENUE
CITY: PALO ALTO
STATE: CA
ZIP: 94301
BUSINESS PHONE: (650) 521-9007
MAIL ADDRESS:
STREET 1: 120 HAWTHORNE AVENUE
CITY: PALO ALTO
STATE: CA
ZIP: 94301
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: SCH Sponsor III LLC
CENTRAL INDEX KEY: 0001806247
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-39252
FILM NUMBER: 211448406
BUSINESS ADDRESS:
STREET 1: 120 HAWTHORNE AVENUE
CITY: PALO ALTO
STATE: CA
ZIP: 94301
BUSINESS PHONE: (650) 521-9007
MAIL ADDRESS:
STREET 1: 120 HAWTHORNE AVENUE
CITY: PALO ALTO
STATE: CA
ZIP: 94301
FORMER NAME:
FORMER CONFORMED NAME: SCH Sponsor Corp. III
DATE OF NAME CHANGE: 20200311
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: CLOVER HEALTH INVESTMENTS, CORP. /DE
CENTRAL INDEX KEY: 0001801170
STANDARD INDUSTRIAL CLASSIFICATION: HOSPITAL & MEDICAL SERVICE PLANS [6324]
IRS NUMBER: 981515192
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
BUSINESS ADDRESS:
STREET 1: 3401 MALLORY LANE, SUITE 210
CITY: FRANKLIN
STATE: TN
ZIP: 37067
BUSINESS PHONE: (201) 432-2133
MAIL ADDRESS:
STREET 1: 3401 MALLORY LANE, SUITE 210
CITY: FRANKLIN
STATE: TN
ZIP: 37067
FORMER COMPANY:
FORMER CONFORMED NAME: CLOVER HEALTH INVESTMENTS, CORP.
DATE OF NAME CHANGE: 20210107
FORMER COMPANY:
FORMER CONFORMED NAME: Social Capital Hedosophia Holdings Corp. III
DATE OF NAME CHANGE: 20200124
4
1
doc4.xml
FORM 4 SUBMISSION
X0306
4
2021-07-07
1
0001801170
CLOVER HEALTH INVESTMENTS, CORP. /DE
CLOV
0001715450
Palihapitiya Chamath
C/O 317 UNIVERSITY AVE, SUITE 200
PALO ALTO
CA
94301
0
0
1
1
See Remarks
0001806665
ChaChaCha SPAC C, LLC
C/O 317 UNIVERSITY AVE, SUITE 200
PALO ALTO
CA
94301
0
0
1
1
Former Director
0001806247
SCH Sponsor III LLC
C/O 317 UNIVERSITY AVE, SUITE 200
PALO ALTO
CA
94301
0
0
1
1
Former Director
Class A Common Stock
2021-07-07
4
J
0
20500000
D
0
I
By SCH Sponsor III LLC
Class A Common Stock
2021-08-16
4
M
0
2245980
A
29158480
I
By ChaChaCha SPAC C LLC
Class A Common Stock
2021-08-20
4
J
0
750000
0.00
D
28408480
I
By ChaChaCha SPAC C LLC
Class A Common Stock
2021-11-22
4
P
0
1739130
5.75
A
1739130
I
By SC Ventures Holdings, LLC
Warrants
11.50
2021-07-07
4
J
0
10933333
D
2026-01-07
Class A Common Stock
10933333
0
I
By SCH Sponsor III LLC
Warrants
2021-08-16
4
M
0
9020000
D
2026-01-07
Class A Common Stock
2245980
0
I
By ChaChaCha SPAC C LLC
Reflects a distribution of securities by SCH Sponsor III LLC (the "Sponsor") made to its members on a pro rata basis.
Reflects securities held by the Sponsor. Messrs. Chamath Palihapitiya and Ian Osborne and ChaChaCha SPAC C LLC ("ChaChaCha") may be deemed to beneficially own the Issuer securities held by the Sponsor on the basis of their direct or indirect interests in the Sponsor or their shared control over the Sponsor, as the case may be. Each of Mr. Palihapitiya, Mr. Osborne and ChaChaCha disclaims beneficial ownership of the Issuer securities held by the Sponsor, except to the extent of such person's pecuniary interest therein.
These warrants were exercised in a "Make-Whole Exercise" prior to a redemption of such warrants by the Issuer. Pursuant to the terms of the warrants relating to a Make-Whole Exercise, the warrants held by ChaChaCha were exercised for 2,245,980 shares of Issuer common stock.
Includes shares of Issuer common stock received by ChaChaCha as part of a pro rata distribution from the Sponsor, which was exempt under Rules 16a-9 and 16a-13 under the Securities Exchange Act of 1934, as amended.
Reflects securities held by ChaChaCha. On the basis of Mr. Palihapitiya's relationship with ChaChaCha, Mr. Palihapitiya may be deemed a beneficial owner of the Issuer securities held by ChaChaCha. Mr. Palihapitiya disclaims beneficial ownership of the Issuer securities held by ChaChaCha, except to the extent of his pecuniary interest therein.
Reflects a distribution of shares by ChaChaCha for no value.
Reflects securities held by SC Ventures Holdings, LLC ("SC Ventures"). On the basis of Mr. Palihapitiya's relationship with SC Ventures, Mr. Palihapitiya may be deemed a beneficial owner of the Issuer securities held by SC Ventures. Mr. Palihapitiya disclaims beneficial ownership of the Issuer securities held by SC Ventures, except to the extent of his pecuniary interest therein.
These warrants were fully vested and exercisable.
Prior to the exercise of the warrants reported herein, these warrants were received by ChaChaCha as part of a pro rata distribution from the Sponsor, which was exempt under Rules 16a-9 and 16a-13 under the Securities Exchange Act of 1934, as amended.
FORMER CHIEF EXECUTIVE OFFICER AND DIRECTOR
CHAMATH PALIHAPITIYA, By: /s/ Chamath Palihapitiya
2021-11-24
CHACHACHA SPAC C, LLC, By: /s/ Chamath Palihapitiya, as Manager
2021-11-24
SCH SPONSOR III LLC, By: /s/ Chamath Palihapitiya, as Chief Executive Officer
2021-11-24