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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 ANNUAL 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 2270 (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 at End of Issuer's Fiscal Year (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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(A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
SHERIDAN MICHAEL J C/O DOCUSIGN, INC. 221 MAIN STREET, SUITE 1550 SAN FRANCISCO, CA 94105 |
Former Chief Financial Officer |
/s/ Poonam Singh, Attorney-in-fact | 01/29/2021 | |
**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) | Represents gifts of the Issuer's Common Stock made by the Reporting Person to his children. The reporting person disclaims beneficial ownership of the shares held by his children, and this report should not be deemed an admission that the reporting person is the beneficial owner of his children's shares for purposes of Section 16 or for any other purpose. |
Remarks: This amendment to Form 5 filed on March 14, 2019 reflects corrections to the number of shares of the Issuer's Common Stock reported as dispositions in connection with gifts made by the Reporting Person on December 26, 2018 and January 2, 2019. Accordingly, the total number of shares of the Issuer's Common Stock reported as directly owned by the Reporting Person in Column 5 of Table I of Forms 4 filed between March 15, 2019 and June 17, 2020 are overstated by 2,000 shares, and the total number of shares of the Issuer's Common Stock reported as indirectly owned by the Reporting Person in Column 5 of Table I of Forms 4 filed between March 15, 2019 and June 17, 2020 are understated by 2,000 shares. |