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-1 Convertible Preferred Stock
|
Â
(1)
|
Â
(1)
|
Common Stock
|
1,544,397
(2)
|
$
0
(1)
|
D
|
Â
|
Convertible Promissory Notes
|
Â
(3)
|
Â
(3)
|
Common Stock
|
$
181,818.18
|
$
(3)
|
D
|
Â
|
Series A-1 Preferred Warrants
|
10/15/2013 |
10/15/2018 |
Series A-1 Preferred Stock
|
532,818
(4)
|
$
0.449
(4)
|
D
|
Â
|
* |
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) |
The shares of Series A-1 Preferred Stock have no expiration date and are convertible at any time at the election of the holder. Each share of Series A-1 Preferred Stock will automatically convert on a one-for-one basis into shares of common stock upon the closing of the Issuer's initial public offering. |
(2) |
Share numbers assume or give effect to the 1-for-12.49 reverse stock split of the Issuer's Common Stock effected on October 25, 2013, which will be effective for the Preferred Stock upon its conversion to Common Stock immediately prior to the closing of the Issuer's initial public offering. |
(3) |
Consists of principal, that together with accrued interest, will convert immediately prior to the closing of the Issuer's initial public offering into shares of Common Stock at a conversion price equal to the public offering price of the Common Stock sold in the Issuer's initial public offering. |
(4) |
Share numbers and exercise price do not give effect to the 1-for-12.49 reverse stock split of the Issuer's Common Stock effected on October 25, 2013, which will be effective for the Preferred Stock upon its conversion to Common Stock immediately prior to the closing of the Issuer's initial public offering |