Statement of Changes in Beneficial Ownership (4)
June 28 2021 - 4:12PM
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
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DUNN JEFFREY W |
2. Issuer Name and Ticker or Trading Symbol
SI-BONE, Inc.
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SIBN
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__X__ Director _____ 10% Owner _____ Officer (give title below) _____ Other (specify below)
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(Last)
(First)
(Middle)
C/O SI-BONE, INC., 471 EL CAMINO REAL, SUITE 101 |
3. Date of Earliest Transaction
(MM/DD/YYYY)
6/24/2021 |
(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 | 6/24/2021 | | M | | 13327.00 | A | $4.32 | 198091.00 | D | |
Common Stock | 6/24/2021 | | S(1) | | 13327.00 | D | $32.2278 (2) | 184764.00 (3) | D | |
Common Stock | | | | | | | | 56128.00 | I | by Trust (4) |
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 |
Stock Option (Right to Buy) | $4.32 | 6/24/2021 | | M | | | 13327.00 | (5) | 5/25/2025 | Common Stock | 13327.00 | $0.00 | 26340.00 | D | |
Explanation of Responses: |
(1) | The sale reported on this Form 4 was effected pursuant to a 10b5-1 trading plan. |
(2) | The price reported in column 4 is a weighted-average price. The shares were sold in multiple transactions ranging from $32.00 to $32.75, inclusive. The Reporting Person undertakes to provide the Issuer, any securityholder of the Issuer, or the Staff of the Securities and Exchange Commission, upon request, full information regarding the number of shares sold at each separate price within the range set forth in this footnotes. |
(3) | Represents shares issuable on the settlement of the net restricted stock units granted and canceled to the Reporting Person. Each restricted
stock unit represents a contingent right to receive one share of the Issuer's common stock. |
(4) | Shares held by The Jeffrey W. Dunn Living Trust Dated May 17, 2012. |
(5) | The shares subject to the option vest in equal monthly installments over four years commencing on vesting commencement date, subject to
Reporting Person's continued service through each relevant vesting date. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
DUNN JEFFREY W C/O SI-BONE, INC. 471 EL CAMINO REAL, SUITE 101 SANTA CLARA, CA 95050 | X |
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Signatures
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/s/ Michael A. Pisetsky, Attorney-in-Fact for Jeffrey W. Dunn | | 6/28/2021 |
**Signature of Reporting Person | Date |
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