Skyline Venture Partners V Form 3 SI-BONE / John Gordon Freund ownership change

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^*

Skyline Venture Partners V LP

(Last) (First) (Middle)

525 UNIVERSITY AVENUE, SUITE 1350

(Street)

PALO ALTO CA 94301

(City) (State) (Zip)

2. Date of Event Requiring Statement (Month/Day/Year)
10/16/2018

3. Issuer Name and Ticker or Trading Symbol
SI-BONE, Inc. [ SIBN ]

4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)

Director	X	10% Owner
Officer (give title below)		Other (specify below)

5. If Amendment, Date of Original Filed (Month/Day/Year)

6. Individual or Joint/Group Filing (Check Applicable Line)

	Form filed by One Reporting Person
X	Form filed by More than One Reporting Person

Table I - Non-Derivative Securities Beneficially Owned
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)

Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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
Series 4 Preferred Stock	(1)	(1)	Common Stock	2,213,425	(1)	I	By Skyline Venture Partners V, L.P.(2)
Series 5 Preferred Stock	(1)	(1)	Common Stock	776,678	(1)	I	By Skyline Venture Partners V, L.P.(2)
Series 6 Preferred Stock	(3)	(3)	Common Stock	652,347	(3)	I	By Skyline Venture Partners V, L.P.(2)
Series 7 Preferred Stock	(1)	(1)	Common Stock	398,676	(1)	I	By Skyline Venture Partners V, L.P.(2)
Warrant (right to buy)	(4)	(4)	Series 5 Preferred Stock	39,421	9.1	I	By Skyline Venture Partners V, L.P.(2)

1. Name and Address of Reporting Person^*

Skyline Venture Partners V LP

(Last) (First) (Middle)

525 UNIVERSITY AVENUE, SUITE 1350

(Street)

PALO ALTO CA 94301

(City) (State) (Zip)

1. Name and Address of Reporting Person^*

Skyline Venture Management V, LLC

(Last) (First) (Middle)

525 UNIVERSITY AVENUE, SUITE 1350

(Street)

PALO ALTO CA 94301

(City) (State) (Zip)

1. Name and Address of Reporting Person^*

Freund John Gordon

(Last) (First) (Middle)

525 UNIVERSITY AVENUE, SUITE 1350

(Street)

PALO ALTO CA 94301

(City) (State) (Zip)

1. Name and Address of Reporting Person^*

KANEKO YASUNORI

(Last) (First) (Middle)

525 UNIVERSITY AVENUE, SUITE 1350

(Street)

PALO ALTO CA 94301

(City) (State) (Zip)

Explanation of Responses:

1. The Issuer's Series 4 Preferred Stock, Series 5 Preferred Stock and Series 7 Preferred Stock will automatically convert into an equal number of shares of Issuer's common stock immediately upon the closing of the Issuer's initial public offering and has no expiration date.

2. Shares held by Skyline Venture Partners V, L.P. ("SVP V"). Skyline Venture Management V, LLC ("LLC") is the general partner of SVP V and as such may be deemed to have voting and investment power with respect to the securities of SVP V. John G. Freund, a member of the Issuer's board of directors, together with Yasunori Kaneko, are the managing directors of LLC and each may be deemed to have voting and investment power with respect to the securities held by SVP V. Dr. Freund and Mr. Kaneko disclaim beneficial ownership of such securities, except to the extent of their pecuniary interest therein.

3. The Issuer's Series 6 Preferred Stock will automatically convert into approximately 1.05878 shares of Issuer's common stock immediately upon the closing of the Issuer's initial public offering and has no expiration date.

4. Shares subject to the warrant are immediately exercisable. The warrant will expire in connection with the closing of the Issuer's initial public offering.

Remarks:

	Skyline Venture Partners V, L.P., By: Skyline Venture Management V, LLC, Its: General Partner, By: /s/ Kerensa Kenny, Attorney-in-Fact	10/16/2018
	Skyline Venture Management V, LLC, By: /s/ Kerensa Kenny, Attorney-in-Fact	10/16/2018
	John G. Freund, /s/ Kerensa Kenny, Attorney-in-Fact	10/16/2018
	Yasunori Kaneko, /s/ Kerensa Kenny, Attorney-in-Fact	10/16/2018
	** Signature of Reporting Person	Date
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