Jennifer Ernst - Nov 10, 2021 Form 3 Insider Report for Tivic Health Systems, Inc. (TIVC)

Role
Chief Executive Officer, Director, 10%+ Owner
Signature
/s/ Jennifer Ernst
Stock symbol
TIVC
Transactions as of
Nov 10, 2021
Transactions value $
$0
Form type
3
Date filed
11/10/2021, 08:11 PM
Next filing
Nov 15, 2021

Transactions Table

Type Sym Class Transaction Value $ Shares Change % * Price $ Shares After Date Ownership Footnotes
holding TIVC Common Stock 1.17M Nov 10, 2021 Direct

Derivative Securities (e.g., puts, calls, warrants, options, convertible securities)

Type Sym Class Transaction Value $ Shares Change % * Price $ Shares After Date Underlying Class Amount Exercise Price Ownership Footnotes
holding TIVC Stock Option (Right to Buy) Nov 10, 2021 Common Stock 57.5K $0.13 Direct F1
holding TIVC Series Seed-2 Convertible Preferred Stock Nov 10, 2021 Common Stock 1.39K Direct F2
holding TIVC Convertible Promissory Note Nov 10, 2021 Common Stock 27K $3.75 Direct F3, F4
* An asterisk sign (*) next to the price indicates that the price is likely invalid.

Explanation of Responses:

Id Content
F1 The option vests as follows: (i) 25% on April 1, 2019, and (ii) the remaining 75% in equal monthly installments over the next 36 months.
F2 The Series Seed-2 Convertible Preferred Stock (the "Preferred Stock") is convertible into shares of the issuer's common stock on a four-for-one basis and has no expiration date. The Preferred Stock will automatically convert into shares of the issuer's common stock immediately prior to closing of the issuer's initial public offering (the "IPO").
F3 Immediately prior to closing of the issuer's IPO, all outstanding principal and accrued but unpaid interest of the Convertible Promissory Note (the "Note") will automatically convert into shares of the issuer's common stock at a conversion price equal to the lesser of (i) the initial public offering price per share of the issuer's common stock, less a 25% discount and (ii) the quotient resulting from dividing $40,000,000 by the issuer's capitalization on a fully diluted basis, as of immediately prior to the IPO closing date.
F4 The Note will mature on June 1, 2023.