SEC Form 3
FORM 3 | UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940 |
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1. Name and Address of Reporting Person*
(Street)
| 2. Date of Event Requiring Statement (Month/Day/Year) 07/24/2019 | 3. Issuer Name and Ticker or Trading Symbol Livongo Health, Inc. [ LVGO ] | |||||||||||||
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
| 5. If Amendment, Date of Original Filed (Month/Day/Year) | ||||||||||||||
6. Individual or Joint/Group Filing (Check Applicable Line)
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Table I - Non-Derivative Securities Beneficially Owned | |||
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1. Title of Security (Instr. 4) | 2. Amount of Securities Beneficially Owned (Instr. 4) | 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 4. Nature of Indirect Beneficial Ownership (Instr. 5) |
Common Stock | 25,000(1) | I | See footnote(2) |
Common Stock | 25,000(1) | I | See footnote(3) |
Common Stock | 25,000(1) | I | See footnote(4) |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
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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: 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 | ||||
Stock Option (right to buy) | (5) | 11/15/2026 | Common Stock | 16,666 | 1.38 | I | See footnote(2) |
Stock Option (right to buy) | (5) | 11/15/2026 | Common Stock | 16,666 | 1.38 | I | See footnote(3) |
Stock Option (right to buy) | (5) | 11/15/2026 | Common Stock | 16,667 | 1.38 | I | See footnote(4) |
Stock Option (right to buy) | (6) | 12/03/2027 | Common Stock | 16,666 | 1.88 | I | See footnote(2) |
Stock Option (right to buy) | (6) | 12/03/2027 | Common Stock | 16,666 | 1.88 | I | See footnote(3) |
Stock Option (right to buy) | (6) | 12/03/2027 | Common Stock | 16,667 | 1.88 | I | See footnote(4) |
Explanation of Responses: |
1. The reported shares are represented by restricted stock units, or RSUs, pursuant to which one half of the RSUs vest on May 25, 2020 and the remaining RSUs vest in four equal quarterly installments beginning on August 25, 2020. |
2. The shares are held of record by The Philip D. Green 2012 Children's Trust FOB Joshua D. Green for which the reporting person's spouse serves as trustee. |
3. The shares are held of record by The Philip D. Green 2012 Children's Trust FOB Justin J. Green for which the reporting person's spouse serves as trustee. |
4. The shares are held of record by The Philip D. Green 2012 Children's Trust FOB Alexandra E. Green for which the reporting person's spouse serves as trustee. |
5. One-fourth of the shares subject to the option vested on September 6, 2017 and 1/48 of the shares vest monthly thereafter. |
6. One-fourth of the shares subject to the option vested on December 4, 2018 and 1/48 of the shares vest monthly thereafter. |
Remarks: |
Exhibit 24 - Power of Attorney |
/s/ Erica Palsis, by power of attorney | 07/24/2019 | |
** Signature of Reporting Person | Date | |
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | ||
* 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). | ||
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. | ||
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. |