SEC FORM 3

SEC Form 3

FORM 3

UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES

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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1. Name and Address of Reporting Person^*

AKKARAJU SRINIVAS

(Last)

(First)

(Middle)

628 MIDDLEFIELD ROAD

(Street)

PALO ALTO

94301

(City)

(State)

(Zip)

2. Date of Event Requiring Statement (Month/Day/Year)
11/18/2020

3. Issuer Name and Ticker or Trading Symbol
Jiya Acquisition Corp. [ JYAC ]

4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)

X	Director	X	10% Owner
	Officer (give title below)		Other (specify below)

5. If Amendment, Date of Original Filed (Month/Day/Year)

6. Individual or Joint/Group Filing (Check Applicable Line)

	Form filed by One Reporting Person
X	Form filed by More than One Reporting Person

Table I - Non-Derivative Securities Beneficially Owned
1. Title of Security (Instr. 4)	2. Amount of Securities Beneficially Owned (Instr. 4)	3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5)	4. Nature of Indirect Beneficial Ownership (Instr. 5)

Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 4)	2. Date Exercisable and Expiration Date (Month/Day/Year)		3. Title and Amount of Securities Underlying Derivative Security (Instr. 4)		4. Conversion or Exercise Price of Derivative Security	5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5)	6. Nature of Indirect Beneficial Ownership (Instr. 5)
1. Title of Derivative Security (Instr. 4)	Date Exercisable	Expiration Date	Title	Amount or Number of Shares	4. Conversion or Exercise Price of Derivative Security	5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5)	6. Nature of Indirect Beneficial Ownership (Instr. 5)
Class B Common Stock⁽¹⁾	⁽¹⁾⁽²⁾	⁽¹⁾⁽²⁾	Class A Common Stock⁽¹⁾⁽²⁾	30,000⁽¹⁾⁽²⁾	⁽¹⁾⁽²⁾	D
Class B Common Stock⁽¹⁾	⁽¹⁾⁽³⁾	⁽¹⁾⁽³⁾	Class A Common Stock⁽¹⁾⁽³⁾	2,417,447⁽¹⁾⁽³⁾	⁽¹⁾⁽³⁾	I	See Footnote⁽³⁾

1. Name and Address of Reporting Person^*

AKKARAJU SRINIVAS

(Last)

(First)

(Middle)

628 MIDDLEFIELD ROAD

(Street)

PALO ALTO

94301

(City)

(State)

(Zip)

Relationship of Reporting Person(s) to Issuer

X	Director	X	10% Owner
	Officer (give title below)		Other (specify below)

1. Name and Address of Reporting Person^*

Jiya Holding Co LLC

(Last)

(First)

(Middle)

628 MIDDLEFIELD ROAD

(Street)

PALO ALTO

94301

(City)

(State)

(Zip)

Relationship of Reporting Person(s) to Issuer

X	Director	X	10% Owner
	Officer (give title below)		Other (specify below)

Explanation of Responses:

1. The shares of Class B Common Stock of the Issuer ("Class B Shares") will automatically convert into shares of Class A Common Stock of the Issuer ("Class A Shares") on a one-for-one basis (subject to certain adjustments for stock splits, stock dividends, reorganizations, recapitalizations and similar transactions) concurrently with or immediately following the consummation of the Issuer's initial business combination, as described in the section entitled "Description of Securities" in the Issuer's Registration Statement on Form S-1 (File No. 333-249808) filed with the Securities and Exchange Commission on November 16, 2020. The Class B Shares have no expiration date.

2. Reflects 30,000 Class B Shares directly held by Dr. Srinivas Akkaraju, M.D., Ph.D. These Class B Shares held by Dr. Akkaraju are subject to forfeiture if Dr. Akkaraju is removed from office as a director or voluntarily resigns from his position with the Issuer at any time before the consummation of the Issuer's initial business combination.

3. Reflects 2,417,447 Class B Shares held by Jiya Holding Company LLC ("Jiya HoldCo"). Jiya HoldCo is wholly owned by Samsara BioCapital, L.P. ("Samsara LP"). Dr. Akkaraju has voting and dispositive control over the Class B Shares held by Jiya HoldCo via Dr. Akkaraju's control of Samsara LP's general partner, Samsara BioCapital GP, LLC. Dr. Akkaraju disclaims beneficial ownership of the reported securities except to the extent of his pecuniary interest therein.

Remarks:

Exhibit 24 - Power of Attorney, Exhibit 99 - Joint Filer Statement

	By: /s/ Srinivas Akkaraju, By: Richard Van Doren, attorney-in-fact	11/18/2020
	By: /s/ Jiya Holding Company LLC, By: Samsara BioCapital, L.P., its sole member, By: Samsara BioCapital GP, LLC, its General Partner, By: Richard Van Doren, its Chief Financial Officer	11/18/2020
	** 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 5 (b)(v).
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