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 |
Series A Preferred Stock
|
Â
(3)
|
Â
(4)
|
Common Stock
|
18,310
|
$
0
|
I
|
See footnote
(1)
|
Series B Preferred Stock
|
Â
(3)
|
Â
(4)
|
Common Stock
|
75,938
|
$
0
|
I
|
See footnote
(1)
|
Series D Preferred Stock
|
Â
(3)
|
Â
(4)
|
Common Stock
|
217,154
|
$
0
|
I
|
See footnote
(1)
|
Preferred Stock Warrant
|
Â
(5)
|
05/25/2022 |
Series D Preferred Stock
(6)
|
45,450
(6)
|
$
4.4
(6)
|
I
|
See footnote
(1)
|
Preferred Stock Warrant
|
Â
(5)
|
07/03/2022 |
Series D Preferred Stock
(7)
|
181,818
(7)
|
$
4.4
(7)
|
I
|
See footnote
(1)
|
Incentive Stock Option
(8)
|
Â
(9)
|
Â
(10)
|
Common Stock
|
271,272
|
$
1.11
|
D
|
Â
|
Stock Option
(8)
|
Â
(9)
|
Â
(10)
|
Common Stock
|
303,446
|
$
1.11
|
D
|
Â
|
* |
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) |
The securities are held by the Kim Blickenstaff Revocable Trust dated April 15, 2010. |
(2) |
Restricted stock issued pursuant to the Issuer's Tandem Diabetes Care, Inc. 2006 Stock Incentive Plan. These shares vested as to 25% on 10/20/2012 and continue to vest in 36 equal monthly installments thereafter, and will automatically vest in full upon consummation of the Issuer's initial public offering. |
(3) |
The securities are immediately convertible. |
(4) |
The expiration date is not relevant to the conversion of these securities. |
(5) |
The warrants are immediately exercisable. |
(6) |
Upon the consummation of the Issuer's initial public offering, these warrants will automatically become exercisable for 27,124 shares of the Issuer's common stock at an exercise price of $7.37 per share. |
(7) |
Upon the consummation of the Issuer's initial public offering, these warrants will automatically become exercisable for 108,509 shares of the Issuer's common stock at an exercise price of $7.37 per share. |
(8) |
Granted pursuant to the Issuer's Tandem Diabetes Care, Inc. 2006 Stock Incentive Plan. |
(9) |
The date of the option was 4/23/2013. All shares subject to the option will vest in 24 equal monthly installments commencing on 4/23/2013. |
(10) |
The expiration date for these options is 10 years from the date of grant. |