Ernst Jennifer 4

4 · Tivic Health Systems, Inc. · Filed Nov 15, 2021

Form 4

Period: 2021-11-12

DirectorChief Executive Officer

Transactions

Conversion
Series Seed-2 Convertible Preferred Stock
2021-11-12−5,566→ 0 total
From: 2021-03-01→ Common Stock (1,391 underlying)
Conversion
Common Stock
2021-11-12+1,391→ 1,172,891 total
Conversion
Convertible Promissory Note
2021-11-12→ 0 total
Exercise: $3.75→ Common Stock (26,986 underlying)
Conversion
Common Stock
2021-11-12+26,986→ 1,199,877 total

Footnotes (3)

[F1]The shares 5,566 shares of Series Seed-2 Convertible Preferred Stock held by the Reporting Person automatically converted into 1,391 shares of the Issuer's common stock on November 12, 2021 in connection with the Issuer's initial public offering (the "IPO"). The Series Seed-2 Convertible Preferred Stock had no expiration date.
[F2]On November 12, 2021, in connection with the Issuer's IPO, the outstanding principal and accrued but unpaid interest of the Convertible Promissory Note (the "Note"), amounting to $100,000 and $1,200, respectively, automatically converted into an aggregate of 26,986 shares of the Issuer's common stock at a conversion price of $3.75 per share, which conversion price was equal to the IPO price per share of the issuer's common stock, less a 25% discount.
[F3]The Note was scheduled to mature on June 1, 2023.

Documents

1 file