Statement of Changes in Beneficial Ownership (4)
March 30 2020 - 4:43PM
Edgar (US Regulatory)
FORM 4
[ ]
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person
*
FRANCIS LAURA |
2. Issuer Name and Ticker or Trading Symbol
SI-BONE, Inc.
[
SIBN
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
_____ Director _____ 10% Owner __X__ Officer (give title below) _____ Other (specify below) Chief Financial Officer |
(Last)
(First)
(Middle)
C/O SI-BONE, INC., 471 EL CAMINO REAL, SUITE 101 |
3. Date of Earliest Transaction
(MM/DD/YYYY)
3/26/2020 |
(Street)
SANTA CLARA, CA 95050
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
_X
_ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security (Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code (Instr. 8)
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4. Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)
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7. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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Amount
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(A) or (D)
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Price
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Common Stock | 3/26/2020 | | A | | 3375.00 (1) | A | $0.00 | 141903.00 (2) | D | |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security (Instr. 3) | 2. Conversion or Exercise Price of Derivative Security | 3. Trans. Date | 3A. Deemed Execution Date, if any | 4. Trans. 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 | 7. Title and Amount of Securities Underlying Derivative Security (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) |
Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Explanation of Responses: |
(1) | Reflects shares issuable on settlement of restricted stock units granted to the Reporting Person. Each restricted stock unit represents a contingent right to receive one shares of the Issuer's common stock. The shares subject to the restricted stock unit vest in lump sum on January 15, 2021, subject to the Reporting Person's continued service through relevant vesting date. |
(2) | Includes 93,876 shares issuable on settlement of restricted stock units granted to the Reporting Person. Each restricted stock unit represents a contingent right to receive one shares of the Issuer's common stock. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
FRANCIS LAURA C/O SI-BONE, INC. 471 EL CAMINO REAL, SUITE 101 SANTA CLARA, CA 95050 |
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| Chief Financial Officer |
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Signatures
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/s/ Michael A. Pisetsky, Attorney-in-Fact for Laura A. Francis | | 3/30/2020 |
**Signature of Reporting Person | Date |
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