0001104659-21-024608.txt : 20210216 0001104659-21-024608.hdr.sgml : 20210216 20210216215226 ACCESSION NUMBER: 0001104659-21-024608 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20201231 FILED AS OF DATE: 20210216 DATE AS OF CHANGE: 20210216 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Roberts Paul Damian CENTRAL INDEX KEY: 0001798701 FILING VALUES: FORM TYPE: 5 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39441 FILM NUMBER: 21642432 MAIL ADDRESS: STREET 1: 111 WEST 28TH STREET CITY: NEW YORK STATE: NY ZIP: 10001 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Kubient, Inc. CENTRAL INDEX KEY: 0001729750 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-COMPUTER INTEGRATED SYSTEMS DESIGN [7373] IRS NUMBER: 821808844 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 228 PARK AVENUE STREET 2: SOUTH SUITE 72602 CITY: NEW YORK STATE: NY ZIP: 10003 BUSINESS PHONE: (800) 409-9456 MAIL ADDRESS: STREET 1: 228 PARK AVENUE STREET 2: SOUTH SUITE 72602 CITY: NEW YORK STATE: NY ZIP: 10003 5 1 tm216792d7_5.xml OWNERSHIP DOCUMENT X0306 5 2020-12-31 0 0 0 0001729750 Kubient, Inc. KBNT 0001798701 Roberts Paul Damian C/O KUBIENT, INC. 228 PARK AVENUE SOUTH, SUITE 72602 NEW YORK NY 10003 1 1 1 0 See Remarks Common Stock 2020-08-14 5 C 0 55541 A 2111073 D Common Stock 2020-11-20 5 A 0 12658 0 A 2123731 D Common Stock Purchase Warrant 5.50 2020-08-14 5 C 0 55541 A 2020-08-14 2025-08-14 Common Stock 55541 55541 D Represents the shares of common stock of Kubient, Inc. (the "Company") issued upon conversion of $277,705 of promissory notes that, upon the initial public offering of the Company, converted into 55,541 immediately-separable units composed of (i) one share of common stock, and (ii) one warrant to purchase one share of common stock at a price of $5.50 per share. Not previously reported on Form 4. Includes 666,667 shares of common stock held by the Paul Roberts 2019 Annuity Trust, of which the Reporting Person is a partial beneficiary. The Reporting Person's spouse is trustee of the trust. The Reporting Person disclaims beneficial ownership of these securities, and the filing of this report is not an admission that the Reporting Person is the beneficial owner of these securities for purposes of Section 16 or for any other purpose. Also includes 55,541 shares of common stock issuable upon exercise of five-year warrants at an exercise price of $5.50 per share. Does not include 29,859 shares of common stock underlying stock options exercisable within 60 days. Also does not include 55,541 shares of common stock underlying five-year warrants issued on August 14, 2020, which are reported on Table II of this Form 5. Represents the warrants to purchase shares of common stock issued upon conversion of $277,705 of promissory notes that, upon the initial public offering of the Company, converted into 55,541 immediately-separable units composed of (i) one share of common stock, and (ii) one warrant to purchase one share of common stock at a price of $5.50 per share. Interim Chief Executive Officer, Chief Strategy Officer, President and Chairman /s/ Paul D. Roberts 2021-02-15