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 Preferred Stock
|
(3)
|
(3)
|
Common Stock
|
1,777
|
$
(3)
|
D
|
|
Series A Preferred Stock
|
(3)
|
(3)
|
Common Stock
|
27,826
|
$
(3)
|
I
|
By Gen 3 Partners, Inc.
(2)
|
Series B Preferred Stock
|
(3)
|
(3)
|
Common Stock
|
82,416
|
$
(3)
|
I
|
By Gen 3 Partners, Inc.
(2)
|
Series C Preferred Stock
|
(3)
|
(3)
|
Common Stock
|
39,697
|
$
(3)
|
I
|
By Gen 3 Partners, Inc.
(2)
|
Series D Preferred Stock
|
(3)
|
(3)
|
Common Stock
|
42,372
|
$
(3)
|
D
|
|
Series D Preferred Stock
|
(3)
|
(3)
|
Common Stock
|
12,309
|
$
(3)
|
I
|
By Gen 3 Partners, Inc.
(2)
|
Series E Preferred Stock
|
(3)
|
(3)
|
Common Stock
|
11,790
|
$
(3)
|
D
|
|
Series E Preferred Stock
|
(3)
|
(3)
|
Common Stock
|
157,515
|
$
(3)
|
I
|
By GEN3 Capital I, LP
(2)
|
Series F Preferred Stock
|
(3)
|
(3)
|
Common Stock
|
7,692
|
$
(3)
|
D
|
|
Series F Preferred Stock
|
(3)
|
(3)
|
Common Stock
|
96,899
|
$
(3)
|
I
|
By GEN3 Capital I, LP
(2)
|
Series G Preferred Stock
|
(3)
|
(3)
|
Common Stock
|
383,995
|
$
(3)
|
I
|
By GEN3 Capital I, LP
(2)
|
Stock Option (Right to Buy)
|
(4)
|
01/24/2017 |
Common Stock
|
3,000
|
$
2.2
|
D
|
|
Stock Option (Right to Buy)
|
(4)
|
12/10/2017 |
Common Stock
|
4,000
|
$
2.2
|
D
|
|
Stock Option (Right to Buy)
|
(4)
|
03/17/2019 |
Common Stock
|
4,000
|
$
2.6
|
D
|
|
Stock Option (Right to Buy)
|
(4)
|
12/03/2019 |
Common Stock
|
4,000
|
$
2.6
|
D
|
|
Stock Option (Right to Buy)
|
(4)
|
01/18/2021 |
Common Stock
|
4,000
|
$
2.6
|
D
|
|
Stock Option (Right to Buy)
|
(4)
|
06/12/2023 |
Common Stock
|
8,000
|
$
2.3
|
D
|
|
Stock Option (Right to Buy)
|
(4)
|
05/12/2024 |
Common Stock
|
4,000
|
$
3.1
|
D
|
|
Stock Option (Right to Buy)
|
(4)
|
06/11/2025 |
Common Stock
|
32,370
|
$
1.6
|
D
|
|
Stock Option (Right to Buy)
|
(4)
|
05/24/2016 |
Common Stock
|
9,510
|
$
1.9
|
D
|
|
Dividend Right
|
(5)
|
(5)
|
Common Stock
|
59,388
|
$
(5)
|
D
|
|
Dividend Right
|
(5)
|
(5)
|
Common Stock
|
33,972
|
$
(5)
|
I
|
By Gen 3 Partners,
Inc
(2)
|
Dividend Right
|
(5)
|
(5)
|
Common Stock
|
351,051
|
$
(5)
|
I
|
By GEN3 Capital I, LP
(2)
|
* |
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 51,246 shares of common stock held by GEN3 Capital I, LP ("GEN3 Capital") and 166,358 shares of common stock held by Gen 3 Partners, Inc. ("Gen 3 Partners"). |
(2) |
The general partner of GEN3 Capital is GEN3 Capital Partners, LLC ("GEN3 LLC"), and Jim K. Sims is the Managing Member of of GEN3 LLC. As a result, each of GEN3 LLC and Mr. Sims may be deemed to share beneficil ownership of the shares of common stock held by GEN3 Capital. Mr. Sims may be deemed to share beneficial ownership of the shares held by Gen 3 Partners in his capacity as a director of Gen 3 Partners. Mr. Simms disclaims such beneficial ownership extent to the extent of his pecuniary interest therein. |
(3) |
The preferred stock is convertible at any time, at the holder's election and has no expiration date. The preferred stock will automatically convert into common stock upon the closing of the Issuer's initial public offering. |
(4) |
The option is fully vested. |
(5) |
The dividend rights are payable in cash or shares of common stock at the Issuer's election immediately upon the closing of the Issuer's initial public offering. |