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 Redeemable Convertible Preferred Stock
|
Â
(4)
|
Â
(4)
|
Common Stock
|
273,638
|
$
(4)
|
I
|
See footnotes
(1)
(2)
|
Series A Redeemable Convertible Preferred Stock
|
Â
(4)
|
Â
(4)
|
Common Stock
|
9,985
|
$
(4)
|
I
|
See footnotes
(2)
(3)
|
Series B Redeemable Convertible Preferred Stock
|
Â
(5)
|
Â
(5)
|
Common Stock
|
197,760
|
$
(5)
|
I
|
See footnotes
(1)
(2)
|
Series B Redeemable Convertible Preferred Stock
|
Â
(5)
|
Â
(5)
|
Common Stock
|
7,216
|
$
(5)
|
I
|
See footnotes
(2)
(3)
|
* |
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) |
Represents securities held directly by FFC Partners III-B, L.P. ("FFC III-B"). |
(2) |
FFC GP III, LLC is the general partner of each of FFC III-B and FFC Executive Partners III, L.P. ("FFC EP III", and together with FFC III-B and FFC GP III, LLC, the FFC Entities). Carlos A. Ferrer, a member of the issuer's board of directors, is a manager of FFC GP III, LLC. Mr. Ferrer disclaims beneficial ownership of all securities held by the FFC Entities, except to the extent of his pecuniary interest therein, if any. |
(3) |
Represents securities held directly by FFC EP III. |
(4) |
The Series A Redeemable Convertible Preferred Stock is convertible into shares of common stock on a one-for-one basis and has no expiration date. Upon the closing of the initial public offering of the issuer's common stock, the issuer's Series A Redeemable Convertible Preferred Stock will automatically convert into shares of the issuer's common stock on a one-for-one basis. |
(5) |
The Series B Redeemable Convertible Preferred Stock is convertible into shares of common stock on a one-for-one basis and has no expiration date. Upon the closing of the initial public offering of the issuer's common stock, the issuer's Series B Redeemable Convertible Preferred Stock will automatically convert into shares of the issuer's common stock on a one-for-one basis. |