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 Convertible Preferred Stock
|
Â
(2)
|
Â
(2)
|
Common Stock
|
42,106
(2)
|
$
(2)
|
D
|
Â
|
Series B Convertible Preferred Stock
|
Â
(3)
|
Â
(3)
|
Common Stock
|
42,105
(3)
|
$
(3)
|
D
|
Â
|
Employee Stock Option (right to buy)
|
Â
(4)
|
08/01/2012 |
Common Stock
|
625
|
$
6
|
D
|
Â
|
Employee Stock Option (right to buy)
|
Â
(4)
|
07/01/2013 |
Common Stock
|
500
|
$
6
|
D
|
Â
|
Employee Stock Option (right to buy)
|
Â
(4)
|
06/30/2014 |
Common Stock
|
500
|
$
6
|
D
|
Â
|
Employee Stock Option (right to buy)
|
Â
(4)
|
04/20/2015 |
Common Stock
|
10,000
|
$
6
|
D
|
Â
|
Employee Stock Option (right to buy)
|
Â
(4)
|
10/18/2020 |
Common Stock
|
10,000
|
$
6.92
|
D
|
Â
|
Employee Stock Option (right to buy)
|
Â
(4)
|
06/28/2021 |
Common Stock
|
625
|
$
11.58
|
D
|
Â
|
Common Stock Warrants (right to buy)
|
Â
(4)
|
10/28/2012 |
Common Stock
|
90,586
|
$
6
|
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) |
These shares are held in a trust for the benefit of the reporting person's children. The reporting person's spouse is trustee of the trust. The reporting person disclaims beneficial ownership of these securities, and the filing of this report is not an admission that the reporting person is the beneficial owner of these securities for purposes of Section 16 or for any other purpose. |
(2) |
Each share of Series A Convertible Preferred Stock will automatically convert into 1.263 shares of common stock in connection with the completion of the Company's initial public offering and has no expiration date. |
(3) |
Each share of Series B Convertible Preferred Stock will automatically convert into one share of common stock in connection with the completion of the Company's initial public offering and has no expiration date. |
(4) |
All options and warrants to purchase shares of common stock are currently exercisable. |