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 of Derivative Security: Direct (D) or Indirect (I) (Instr. 5) |
6. Nature of Indirect Beneficial Ownership (Instr. 5) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
Convertible Promissory Note
|
Â
(3)
|
Â
(3)
|
Common Stock
|
$
150,000
(3)
|
$
(3)
|
D
|
Â
|
Convertible Promissory Note
|
Â
(3)
|
Â
(3)
|
Common Stock
|
$
1,474,960
(3)
|
$
(3)
|
I
|
See Footnote
(2)
|
Common Stock Warrant
|
Â
(4)
|
06/14/2023 |
Common Stock
|
(4)
|
$
(4)
|
I
|
See Footnote
(2)
|
* |
If the form is filed by more than one reporting person, see Instruction 5(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) |
Securities held by Saffron Hill Ventures, L.P. Shawn Luetchens and Ranjeet Bhatia are Directors of Saffron Hill MGP Ltd, the General Partner of Saffron Hill Ventures, L.P., and therefore may be deemed to share voting control and investment power over the securities held by Saffron Hill Ventures, L.P. |
(2) |
Securities held by Saffron Hill Ventures 2, L.P. Shawn Luetchens and Ranjeet Bhatia are Directors of Saffron Hill MGP2 Ltd, the General Partner of Saffron Hill Ventures 2, L.P., and therefore may be deemed to share voting control and investment power over the securities held by Saffron Hill Ventures 2, L.P. |
(3) |
Lists original principal under the convertible promissory note as of March 15, 2012, the date of purchase. Upon completion of the Issuer's initial public offering, such principal, plus all accrued interest, will automatically convert into common stock at a price per share equal to 70% of the price per share in the Issuer's initial public offering. |
(4) |
The warrant is exercisable upon completion of the Issuer's initial public offering for a number of shares equal to $200,000 divided by 70% of the price per share in the Issuer's initial public offering and at an exercise price per share equal to 70% of the price per share in the Issuer's initial public offering. |