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
(3)
|
Common Stock
|
5,516
|
$
0
(2)
|
I
|
By River Cities Capital Fund II Limited Partnership
(1)
|
Series B Convertible Preferred Stock
|
Â
(2)
|
Â
(3)
|
Common Stock
|
592,488
|
$
0
(2)
|
I
|
By River Cities Capital Fund II Limited Partnership
(1)
|
Series C Convertible Preferred Stock
|
Â
(2)
|
Â
(3)
|
Common Stock
|
66,750
|
$
0
(2)
|
I
|
By River Cities Capital Fund II Limited Partnership
(1)
|
Series A Convertible Preferred Stock
|
Â
(2)
|
Â
(3)
|
Common Stock
|
10,387
|
$
0
(2)
|
I
|
By River Cities SBIC III, L.P.
(4)
|
Series B Convertible Preferred Stock
|
Â
(2)
|
Â
(3)
|
Common Stock
|
694,265
|
$
0
(2)
|
I
|
By River Cities SBIC III, L.P.
(4)
|
Series C Convertible Preferred Stock
|
Â
(2)
|
Â
(3)
|
Common Stock
|
560,282
|
$
0
(2)
|
I
|
By River Cities SBIC III, L.P.
(4)
|
* |
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) |
Represents securities held directly by River Cities Capital Fund II Limited Partnership. Mayson II, Inc. is the general partner of River Cities Management II, L.P., the general partner of River Cities Capital Fund II Limited Partnership. The reporting person is a special consultant to River Cities Management II, L.P. The reporting person may be deemed to be an indirect beneficial owner of the reported securities. The reporting person disclaims any beneficial ownership of the reported securities, except to the extent of any pecuniary interest therein. This report shall not be deemed an admission that the reporting person is the beneficial owner of such securities for purposes of Section 16 or for any other purpose. |
(2) |
Each share of Series A, Series B, and Series C Convertible Preferred Stock is convertible at any time at the option of the holder, and will automatically convert into shares of the Issuer's Common Stock on a one-for-one basis in connection with the closing of the Issuer's initial public offering. |
(3) |
The securities do not have an expiration date. The securities will automatically convert into shares of the Issuer's Common Stock on a one-for-one basis in connection with the closing of the Issuer's initial public offering. |
(4) |
Represents securities held directly by River Cities SBIC III, L.P., which is managed by RCCF Management, Inc. The reporting person is a special consultant to RCCF Management, Inc. The reporting person may be deemed to be an indirect beneficial owner of the reported securities. The reporting person disclaims any beneficial ownership of the reported securities, except to the extent of any pecuniary interest therein. This report shall not be deemed an admission that the reporting person is the beneficial owner of such securities for purposes of Section 16 or for any other purpose. |