SEC Form 4
FORM 4 | UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP 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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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). |
1. Name and Address of Reporting Person*
(Street)
| 2. Issuer Name and Ticker or Trading Symbol Restoration Robotics Inc [ HAIR ] | 5. Relationship of Reporting Person(s) to Issuer (Check all applicable)
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3. Date of Earliest Transaction (Month/Day/Year) 10/16/2017 | ||||||||||||||||||||||||||
4. 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 Acquired, Disposed of, or Beneficially Owned | ||||||||||
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1. Title of Security (Instr. 3) | 2. Transaction Date (Month/Day/Year) | 2A. Deemed Execution Date, if any (Month/Day/Year) | 3. Transaction Code (Instr. 8) | 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) | 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) | 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 7. Nature of Indirect Beneficial Ownership (Instr. 4) | |||
Code | V | Amount | (A) or (D) | Price | ||||||
Common Stock | 10/16/2017 | C | 2,116 | A | $0(1) | 2,116 | D | |||
Common Stock | 10/16/2017 | C | 7,692 | A | $0(1) | 7,692 | I | By Ltd Partnership (ROOS)(2) | ||
Common Stock | 10/16/2017 | C | 2,257 | A | $0(1) | 9,949 | I | By Ltd Partnership (ROOS)(2) | ||
Common Stock | 10/16/2017 | C | 888,690 | A | $0(1) | 888,690 | I | By Ltd Partnership (SHV)(3) | ||
Common Stock | 10/16/2017 | C | 606,386 | A | $0(1) | 1,495,076 | I | By Ltd Partnership (SHV)(3) | ||
Common Stock | 10/16/2017 | C | 479,145 | A | $0(1) | 1,974,221 | I | By Ltd Partnership (SHV)(3) | ||
Common Stock | 10/16/2017 | C | 105,369 | A | $7 | 2,079,590 | I | By Ltd Partnership (SHV)(3) | ||
Common Stock | 10/16/2017 | C | 102,894 | A | $0(1) | 102,894 | I | By Profit Sharing Plan Trust(4) | ||
Common Stock | 10/16/2017 | C | 35,264 | A | $0(1) | 138,158 | I | By Profit Sharing Plan Trust(4) | ||
Common Stock | 10/16/2017 | C | 22,461 | A | $7 | 160,619 | I | By Profit Sharing Plan Trust(4) | ||
Common Stock | 10/16/2017 | C | 96,844 | A | $0(1) | 96,844 | I | By Trust(5) | ||
Common Stock | 10/16/2017 | C | 89,830 | A | $0(1) | 186,674 | I | By Trust(5) | ||
Common Stock | 10/16/2017 | C | 83,948 | A | $0(1) | 270,622 | I | By Trust(5) |
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||||||||||
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1. Title of Derivative Security (Instr. 3) | 2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) | 6. Date Exercisable and Expiration Date (Month/Day/Year) | 7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4) | 8. Price of Derivative Security (Instr. 5) | 9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) | 10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 11. Nature of Indirect Beneficial Ownership (Instr. 4) | ||||
Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||||||
Series C Preferred Stock | (1) | 10/16/2017 | C | 2,116 | (1) | (1) | Common Stock | 2,116 | (1) | 0.0000 | D(6) | ||||
Series B Preferred Stock | (1) | 10/16/2017 | C | 7,692 | (1) | (1) | Common Stock | 7,692 | (1) | 0.0000 | I | By Ltd Partnership (ROOS)(2) | |||
Series C Preferred Stock | (1) | 10/16/2017 | C | 2,257 | (1) | (1) | Common Stock | 2,257 | (1) | 0.0000 | I | By Ltd Partnership (ROOS)(2) | |||
Convertible Promissory Note | $7 | 10/16/2017 | C | 105,369(7) | (8) | (8) | Common Stock | 105,369(7) | (8) | 0.0000 | I | By Ltd Partnership (SHV)(3) | |||
Series B Preferred Stock | (1) | 10/16/2017 | C | 606,386 | (1) | (1) | Common Stock | 606,386 | (1) | 0.0000 | I | By Ltd Partnership (SHV)(3) | |||
Series C Preferred Stock | (1) | 10/16/2017 | C | 888,690 | (1) | (1) | Common Stock | 888,690 | (1) | 0.0000 | I | By Ltd Partnership (SHV)(3) | |||
Convertible Promissory Note | $7 | 10/16/2017 | C | 22,461(7) | (8) | (8) | Common Stock | 22,461(7) | (8) | 0.0000 | I | By Profit Sharing Plan Trust(4) | |||
Series A Preferred Stock | (1) | 10/16/2017 | C | 35,264 | (1) | (1) | Common Stock | 35,264 | (1) | 0.0000 | I | By Profit Sharing Plan Trust(4) | |||
Series C Preferred Stock | (1) | 10/16/2017 | C | 102,894 | (1) | (1) | Common Stock | 102,894 | (1) | 0.0000 | I | By Profit Sharing Plan Trust(4) | |||
Series A Preferred Stock | (1) | 10/16/2017 | C | 89,830 | (1) | (1) | Common Stock | 89,830 | (1) | 0.0000 | I | By Trust(5) | |||
Series B Preferred Stock | (1) | 10/16/2017 | C | 96,844 | (1) | (1) | Common Stock | 96,844 | (1) | 0.0000 | I | By Trust(5) | |||
Series C Preferred Stock | (1) | 10/16/2017 | C | 83,948 | (1) | (1) | Common Stock | 83,948 | (1) | 0.0000 | I | By Trust(5) |
Explanation of Responses: |
1. The issuer's preferred stock will automatically convert into issuer's common stock on a one-to-one basis immediately prior to the closing of the issuer's initial public offering and has no expiration date. |
2. Shares held by a limited partnership of which the reporting person is a trustee of a trust which is the general partner. The reporting person disclaims beneficial ownership in these shares except as to the reporting person's pecuniary interest therein. |
3. Shares held by Sutter Hill Ventures, a California Limited Partnership. The reporting person is a managing director and member of the management committee of the general partner of Sutter Hill Ventures, a California Limited Partnership. The reporting person disclaims beneficial ownership in these shares except as to the reporting person's pecuniary interest therein. |
4. Shares held by the SHV Profit Sharing Plan, a retirement trust, for the benefit of the reporting person. |
5. Shares held by a trust of which the reporting person is a trustee. The reporting person disclaims beneficial ownership in these shares except as to the reporting person's pecuniary interest therein. |
6. Shares held by an individual retirement account, for the benefit of the reporting person. |
7. This reported amount represents the number of shares issuable upon the conversion of the principal and accrued interest of the convertible promissory note held by the reporting person. |
8. The outstanding principal and accrued interest of the reporting person's convertible promissory note automatically converted into shares of the issuer's common stock at the price per share available to the public as set forth in the final prospectus related to the initial public offering upon closing of the initial public offering. |
/s/ Robert Yin, by power of attorney | 10/18/2017 | |
** 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 4 (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. |