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) 10/11/2018 | 3. Issuer Name and Ticker or Trading Symbol Anaplan, Inc. [ PLAN ] | |||||||||||||
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 | 145,304 | I | By Shasta Ventures II, L.P.(1) |
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 | ||||
Series A Convertible Preferred Stock | (2) | (2) | Common Stock | 37,569 | (2) | I | By Shasta Ventures II, L.P.(1) |
Series B Convertible Preferred Stock | (2) | (2) | Common Stock | 8,876,265 | (2) | I | By Shasta Ventures II, L.P.(1) |
Series C Convertible Preferred Stock | (2) | (2) | Common Stock | 3,136,369 | (2) | I | By Shasta Ventures II, L.P.(1) |
Series D Convertible Preferred Stock | (2) | (2) | Common Stock | 984,044 | (2) | I | By Shasta Ventures II, L.P.(1) |
Series E Convertible Preferred Stock | (2) | (2) | Common Stock | 247,547 | (2) | I | By Shasta Ventures II, L.P.(1) |
Explanation of Responses: |
1. Shasta Ventures II GP, LLC is the general partner of Shasta Ventures II, L.P. Ravi Mohan, a member of the issuer's Board of Directors, Robert Coneybeer, Tod Francis, and Jason Pressman are the managing members of Shasta Ventures II GP, LLC and each of them may be deemed to exercise voting and investment power over the shares held of record by Shasta Ventures II, L.P. These individuals disclaim beneficial ownership of the shares held by the aforementioned entities except to the extent of any pecuniary interest therein. |
2. The reported security is convertible into the Issuer's Common Stock on a 1-for-1 basis at any time at the holder's election and shall automatically convert into Common Stock immediately prior to the closing of the Issuer's initial public offering without payment of further consideration. The shares have no expiration date. |
Remarks: |
/s/ Suhani Akhare, Attorney-in-Fact | 10/11/2018 | |
** 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. |