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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT 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 |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Partech U.S. Partners IV, L.L.C. 200 CALIFORNIA ST., STE 500 SAN FRANCISCO, CA 94111 |
X | |||
Partech International Growth Capital I LLC 200 CALIFORNIA ST., STE 500 SAN FRANCISCO, CA 94111 |
X | |||
Partech International Growth Capital II LLC 200 CALIFORNIA ST., STE 500 SAN FRANCISCO, CA 94111 |
X | |||
Partech International Growth Capital III LLC 200 CALIFORNIA ST., STE 500 SAN FRANCISCO, CA 94111 |
X | |||
AXA Growth Capital II LP 200 CALIFORNIA ST., STE 500 SAN FRANCISCO, CA 94111 |
X | |||
45th Parallel LLC 200 CALIFORNIA ST., STE 500 SAN FRANCISCO, CA 94111 |
X | |||
PAR SF II, L.L.C. 200 CALIFORNIA ST., STE 500 SAN FRANCISCO, CA 94111 |
X | |||
46th Parallel LLC 200 CALIFORNIA ST., STE 500 SAN FRANCISCO, CA 94111 |
X | |||
47th Parallel LLC 200 CALIFORNIA ST., STE 500 SAN FRANCISCO, CA 94111 |
X | |||
48th Parallel LLC 200 CALIFORNIA ST., STE 500 SAN FRANCISCO, CA 94111 |
X |
/s/ Vincent R. Worms, managing member of 47th Parallel, L.L.C., the managing member of the Reporting Person | 12/04/2015 | |
**Signature of Reporting Person | Date | |
/s/ Vincent R. Worms, managing member of 45th Parallel, L.L.C., the managing member of 46th Parallel, L.L.C., the managing member of the Reporting Owner | 12/04/2015 | |
**Signature of Reporting Person | Date | |
/s/ Vincent R. Worms, managing member of 45th Parallel, L.L.C., the managing member of 46th Parallel, L.L.C., the managing member of the Reporting Owner | 12/04/2015 | |
**Signature of Reporting Person | Date | |
/s/ Vincent R. Worms, managing member of 45th Parallel, L.L.C., the managing member of 46th Parallel, L.L.C., the managing member of the Reporting Owner | 12/04/2015 | |
**Signature of Reporting Person | Date | |
/s/ Vincent R. Worms, managing member of 48th Parallel, L.L.C., the Investment General Partner of the Reporting Owner | 12/04/2015 | |
**Signature of Reporting Person | Date | |
/s/ Vincent R. Worms, managing member of the Reporting Owner | 12/04/2015 | |
**Signature of Reporting Person | Date | |
/s/ Vincent R. Worms, sole member of the Reporting Owner | 12/04/2015 | |
**Signature of Reporting Person | Date | |
/s/ Vincent R. Worms, managing member of 45th Parallel, L.L.C., the managing member of the Reporting Owner | 12/04/2015 | |
**Signature of Reporting Person | Date | |
/s/ Vincent R. Worms, managing member of the Reporting Owner | 12/04/2015 | |
**Signature of Reporting Person | Date | |
/s/ Vincent R. Worms, managing member of the Reporting Owner | 12/04/2015 | |
**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) | Vincent R. Worms is (A) the sole member of Par SF II L.L.C. ("Par SF"), (B) the managing member of 47th Parallel, L.L.C. ("47th Parallel"), which is the managing member of Partech U.S. Partners IV, L.L.C. ("Partech US"), (C) the managing member of 45th Parallel L.L.C. ("45th Parallel"), which is the managing member of 46th Parallel L.L.C. ("46th Parallel"), which is the managing member of Partech International Growth Capital I L.L.C. ("Partech I"), Partech International Growth Capital II L.L.C.("Partech II") and Partech International Growth Capital III L.L.C. ("Partech III") |
(2) | (Continued from footnote1) and (D) the managing member of 48th Parallel L.L.C. ("48th Parallel"), which is the investment general partner of AXA Growth Capital II L.P. ("AXA"). |
(3) | Vincent R. Worms may be deemed to have voting control and investment power over the securities held by Par SF, Partech US, 45th Parallel, Partech I, Partech II, Partech III and AXA, but disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein. |
Remarks: Form 1 of 2 Five9, Inc. shares were distributed out to various partners by Partech I, Partech II, Partech III and AXA. |