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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT OF CHANGES IN 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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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | |||
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 control number. | SEC 1474 (9-02) |
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 Underlying Securities (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 of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
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Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||||||
Series B Preferred Stock | (1) | 11/15/2021 | C | 2,218,469 | (1) | (1) | Common Stock | 2,218,469 | $ 0 | 0 | I | See footnote (2) | |||
Series B Preferred Stock | (1) | 11/15/2021 | C | 151,690 | (1) | (1) | Common Stock | 151,690 | $ 0 | 0 | I | See footnote (3) | |||
Series B-1 Preferred Stock | (1) | 11/15/2021 | C | 1,122,344 | (1) | (1) | Common Stock | 1,122,344 | $ 0 | 0 | I | See footnote (2) | |||
Series B-1 Preferred Stock | (1) | 11/15/2021 | C | 76,740 | (1) | (1) | Common Stock | 76,740 | $ 0 | 0 | I | See footnote (3) | |||
Series C Preferred Stock | (1) | 11/15/2021 | C | 433,917 | (1) | (1) | Common Stock | 433,917 | $ 0 | 0 | I | See footnote (2) | |||
Series C Preferred Stock | (1) | 11/15/2021 | C | 29,669 | (1) | (1) | Common Stock | 29,669 | $ 0 | 0 | I | See footnote (3) | |||
Series D Preferred Stock | (1) | 11/15/2021 | C | 40,375 | (1) | (1) | Common Stock | 40,375 | $ 0 | 0 | I | See footnote (2) | |||
Series D Preferred Stock | (1) | 11/15/2021 | C | 2,761 | (1) | (1) | Common Stock | 2,761 | $ 0 | 0 | I | See footnote (3) |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Modersitzki Blake G 2750 E. COTTONWOOD PARK, SUITE 600 SALT LAKE CITY, UT 84121 |
X |
/s/ Blake G. Modersitzki | 11/17/2021 | |
**Signature of Reporting Person | Date |
* | 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). |
(1) | Each share of the Series B Preferred Stock, Series B-1 Preferred Stock, Series C Preferred Stock and Series D Preferred Stock automatically converted into shares of Common Stock immediately prior to the closing of the Issuer's initial public offering, on a 1:1 basis, and has no expiration date. |
(2) | Shares are held by Pelion Ventures VI, L.P. ("PV VI"). Pelion Venture Partners VI, L.L.C. ("PVP VI") is the sole general partner of PV VI. The Reporting Person is the managing director of PVP VI and may be deemed to exercise voting and dispositive power over the shares held by PV VI. The Reporting Person disclaims beneficial ownership of the shares held by PV VI except to the extent of his pecuniary interest therein. |
(3) | Shares are held by Pelion Ventures VI-A, L.P. ("PV VI-A"). PVP VI is the sole general partner of PV VI-A. The Reporting Person is the managing director of PVP VI and may be deemed to exercise voting and dispositive power over the shares held by PV VI-A. The Reporting Person disclaims beneficial ownership of the shares held by PV VI-A except to the extent of his pecuniary interest therein. |
(4) | Shares are held by Pelion Ventures VII, L.P. ("PV VII"). Pelion Venture Partners VII, L.L.C. ("PVP VII") is the sole general partner of PV VII. The Reporting Person is a managing director of PVP VII and may be deemed to share voting and dispositive power over the shares held by PV VII. The Reporting Person disclaims beneficial ownership of the shares held by PV VII except to the extent of his pecuniary interest therein. |