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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 STATEMENT 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 Preferred Stock | (1) | 05/01/2018 | C | 1,944,674 | (1) | (1) | Common Stock | 1,987,319 | $ 0 | 0 | I | See footnote (4) | |||
Series A-1 Preferred Stock | (3) | 05/01/2018 | C | 948,167 | (3) | (3) | Common Stock | 948,167 | $ 0 | 0 | I | See footnote (4) | |||
Series B Preferred Stock | (3) | 05/01/2018 | C | 4,729,005 | (3) | (3) | Common Stock | 4,729,005 | $ 0 | 0 | I | See footnote (4) | |||
Series B-1 Preferred Stock | (3) | 05/01/2018 | C | 855,646 | (3) | (3) | Common Stock | 855,646 | $ 0 | 0 | I | See footnote (4) | |||
Series C Preferred Stock | (3) | 05/01/2018 | C | 942,427 | (3) | (3) | Common Stock | 942,427 | $ 0 | 0 | I | See footnote (4) | |||
Series D Preferred Stock | (3) | 05/01/2018 | C | 170,295 | (3) | (3) | Common Stock | 170,295 | $ 0 | 0 | I | See footnote (4) |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Darling Scott C C/O DOCUSIGN, INC. 221 MAIN ST., SUITE 1000 SAN FRANCISCO, CA 94105 |
X |
/s/ Yanira Wong, Attorney-in-fact | 05/01/2018 | |
**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 Series A Preferred Stock converted into 1.02192925205 shares of common stock upon the closing of the Issuer's initial public offering. The shares had no expiration date. |
(2) | The shares are owned directly by Frazier Technology Ventures II, L.P. ("Frazier"). Frazier's sole general partner is FTVM II, L.P. ("FTVM II") and FTVM II's sole general partner is Frazier Technology Management, L.L.C. ("Frazier Tech Management"). Scott Darling is a managing member of Frazier Tech Management. The reporting person disclaims beneficial ownership of these securities, except to the extent of his pecuniary interest therein, and this report shall not be deemed an admission that the reporting person is the beneficial owner of such securities for Section 16 or any other purpose. |
(3) | Each share of Series A-1 Preferred Stock, Series B Preferred Stock, Series B-1 Preferred Stock, Series C Preferred Stock and Series D Preferred Stock converted into one share of common stock upon the closing of the Issuer's initial public offering. The shares had no expiration date. |
(4) | The shares were held by Frazier. Frazier's sole general partner is FTVM II and FTVM II's sole general partner is Frazier Tech Management. Scott Darling is a managing member of Frazier Tech Management. The reporting person disclaims beneficial ownership of these securities, except to the extent of his pecuniary interest therein, and this report shall not be deemed an admission that the reporting person is the beneficial owner of such securities for Section 16 or any other purpose. |