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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, Section 17(a) of the Public Utility Holding Company Act of 1935 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 A Convertible Preferred Stock | (1) | 07/23/2014 | C | 3,673,730 | (1) | (1) | Common Stock | 3,673,730 | $ 0 | 0 | I | By Maveron Equity Partners III, L.P. (2) | |||
Series A Convertible Preferred Stock | (1) | 07/23/2014 | C | 155,880 | (1) | (1) | Common Stock | 155,880 | $ 0 | 0 | I | By Maveron III Entrepreneurs? Fund L.P. (5) | |||
Series A Convertible Preferred Stock | (1) | 07/23/2014 | C | 503,720 | (1) | (1) | Common Stock | 503,720 | $ 0 | 0 | I | By MEP Associates III, L.P. (6) | |||
Series B Convertible Preferred Stock | (3) | 07/23/2014 | C | 1,210,920 | (3) | (3) | Common Stock | 1,210,920 | $ 0 | 0 | I | By Maveron Equity Partners III, L.P. (2) | |||
Series B Convertible Preferred Stock | (3) | 07/23/2014 | C | 51,364 | (3) | (3) | Common Stock | 51,364 | $ 0 | 0 | I | By Maveron III Entrepreneurs? Fund L.P. (5) | |||
Series B Convertible Preferred Stock | (3) | 07/23/2014 | C | 166,032 | (3) | (3) | Common Stock | 166,032 | $ 0 | 0 | I | By MEP Associates III, L.P. (6) | |||
Series C Convertible Preferred Stock | (4) | 07/23/2014 | C | 545,165 | (4) | (4) | Common Stock | 545,165 | $ 0 | 0 | I | By Maveron Equity Partners III, L.P. (2) | |||
Series C Convertible Preferred Stock | (4) | 07/23/2014 | C | 23,131 | (4) | (4) | Common Stock | 23,131 | $ 0 | 0 | I | By Maveron III Entrepreneurs? Fund L.P. (5) | |||
Series C Convertible Preferred Stock | (4) | 07/23/2014 | C | 74,750 | (4) | (4) | Common Stock | 74,750 | $ 0 | 0 | I | By MEP Associates III, L.P. (6) |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
LEVITAN DAN C/O TRUPANION, INC. 907 NW BALLARD WAY SEATTLE, WA 98107 |
X | X |
/s/ Charlotte Sim-Warner as attorney-in-fact for Dan Levitan | 07/23/2014 | |
**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 issuer's Series A Convertible Preferred Stock converted into 1 share of the issuer's Common Stock on July 23, 2014 in connection with the closing of the issuer's sale of its Common Stock in its firm commitment initial public offering (the "IPO") pursuant to a registration statement on Form S-1 (File No. 333-196814) under the Securities Act of 1933, as amended (the "Registration Statement"), and had no expiration date. |
(2) | The reporting person, together with Clayton Lewis, Peter McCormick and Jason Stoffer, are members of Maveron General Partner III LLC ("Maveron LLC"), which is the general partner of Maveron Equity Partners III, L.P. ("Maveron Equity"), and may be deemed to share voting and investment power over the securities held by Maveron Equity. The reporting person disclaims beneficial ownership over such securities except to the extent of his pecuniary interest therein, and the inclusion of these securities in this report shall not be deemed an admission of beneficial ownership of the reported securities for purposes of Section 16 or for any other purposes. |
(3) | Each share of the issuer's Series B Convertible Preferred Stock converted into 1 share of the issuer's Common Stock on July 23, 2014 in connection with the closing of the issuer's sale of its Common Stock in its IPO pursuant to the Registration Statement, and had no expiration date. |
(4) | Each share of the issuer's Series C Convertible Preferred Stock converted into 1 share of the issuer's Common Stock on July 23, 2014 in connection with the closing of the issuer's sale of its Common Stock in its IPO pursuant to the Registration Statement, and had no expiration date. |
(5) | The reporting person, together with Clayton Lewis, Peter McCormick and Jason Stoffer, are members of Maveron LLC, which is the General Partner of Maveron III Entrepreneurs' Fund L.P. ("Maveron Entrepreneurs"), and may be deemed to share voting and investment power over the securities held by Maveron Entrepreneurs. The reporting person disclaims beneficial ownership over such securities except to the extent of his pecuniary interest therein. The inclusion of these securities in this report shall not be deemed an admission of beneficial ownership of the reported securities for purposes of Section 16 or for any other purposes. |
(6) | The reporting person, together with Clayton Lewis, Peter McCormick and Jason Stoffer, are members of Maveron LLC, which is the General Partner of MEP Associates III, L.P. ("MEP"), and may be deemed to share voting and investment power over the securities held by MEP. The reporting person disclaims beneficial ownership over such securities except to the extent of his pecuniary interest therein. The inclusion of these securities in this report shall not be deemed an admission of beneficial ownership of the reported securities for purposes of Section 16 or for any other purposes. |