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)
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2. Date of Event Requiring Statement
(Month/Day/Year) 09/18/2023 |
3. Issuer Name and Ticker or Trading Symbol
Maplebear Inc. [ CART ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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5. If Amendment, Date of Original Filed
(Month/Day/Year) |
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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) |
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 Preferred Stock | (1) | (1) | Common Stock | 295,465 | (1) | I | By a16z Seed-III, LLC(2)(3) |
Series B Preferred Stock | (4) | (4) | Common Stock | 3,766,368 | (4) | I | By AH Parallel Fund IV, L.P., as nominee(3)(5) |
Series B Preferred Stock | (4) | (4) | Common Stock | 5,190,455 | (4) | I | By Andreessen Horowitz Fund IV, L.P., as nominee(3)(6) |
Series C Preferred Stock | (1) | (1) | Common Stock | 379,105 | (1) | I | By AH Parallel Fund IV, L.P., as nominee(3)(5) |
Series C Preferred Stock | (1) | (1) | Common Stock | 522,440 | (1) | I | By Andreessen Horowitz Fund IV, L.P., as nominee(3)(6) |
Series D Preferred Stock | (1) | (1) | Common Stock | 567,630 | (1) | I | By AH Parallel Fund IV, L.P., as nominee(3)(5) |
Series D Preferred Stock | (1) | (1) | Common Stock | 782,255 | (1) | I | By Andreessen Horowitz Fund IV, L.P. as nominee(3)(6) |
Series D Preferred Stock | (1) | (1) | Common Stock | 65,014 | (1) | I | By Andreessen Horowitz LSV Fund I, L.P., as nominee(3)(7) |
Series I Preferred Stock | (1) | (1) | Common Stock | 400,000 | (1) | I | By Andreessen Horowtiz LSV Fund I, L.P., as nominee(3)(7) |
Explanation of Responses: |
1. The Series A Preferred Stock, Series C Preferred Stock, Series D Preferred Stock and Series I Preferred Stock each is convertible on a one-for-one basis into common stock at any time at the holder's election and will convert automatically upon the closing of the Issuer's initial public offering and has no expiration date. |
2. The shares are held of record by a16z Seed-III, LLC. |
3. Mr. Jordan is a member of the general partners of the AH Fund Entities (as defined herein), but he disclaims the existence of a "group" and disclaims beneficial ownership of the shares held by the Andreessen Horowitz Entities and this report shall not be deemed an admission that he is the beneficial owner of such shares, except to the extent of his pecuniary interest, if any, in such shares by virtue of his interest in the AH Fund Entities, and/or the general partner entities thereof, as applicable. |
4. The Series B Preferred Stock is convertible on a 1.024566722-for-1 basis into common stock at any time at the holder's election and will convert automatically upon the closing of the Issuer's initial public offering and has no expiration date. |
5. The shares are held of record by AH Parallel Fund IV, L.P., for itself and as nominee for AH Parallel Fund IV-A, L.P., AH Parallel Fund IV-B, L.P. and AH Parallel Fund IV-Q, L.P. (collectively, the "AH Parallel Fund IV Entities"). AH Equity Partners IV (Parallel), L.L.C. ("AH EP IV Parallel") is the general partner of the AH Parallel Fund IV Entities and has sole voting and dispositive power with regard to the shares held by the AH Parallel Fund IV Entities. The managing members of AH EP IV Parallel are Marc Andreessen and Benjamin Horowitz. Marc Andreessen and Benjamin Horowitz share voting and dispositive power with respect to the shares held by the AH Parallel Fund IV Entities. |
6. The shares are held of record by Andreessen Horowitz Fund IV, L.P., for itself and as nominee for Andreessen Horowitz Fund IV-A, L.P., Andreessen Horowitz Fund IV-B, L.P. and Andreessen Horowitz Fund IV-Q, L.P. (collectively, the "AH Fund IV Entities"). AH Equity Partners IV, L.L.C. ("AH EP IV") is the general partner of the AH Fund IV Entities and has sole voting and dispositive power with regard to the shares held by the AH Fund IV Entities. The managing members of AH EP IV are Marc Andreessen and Benjamin Horowitz. Marc Andreessen and Benjamin Horowitz share voting and dispositive power with respect to the shares held by the AH Fund IV Entities. |
7. The shares are held of record by Andreessen Horowitz LSV Fund I, L.P., for itself and as nominee for Andreessen Horowitz LSV Fund I-B, L.P. and Andreessen Horowitz LSV Fund I-Q, L.P. (collectively, the "AH LSV Fund I Entities", and together with the AH Fund IV Entities, the AH Parallel Fund IV Entities and a16z Seed-III, LLC, the "AH Fund Entities"). AH Equity Partners LSV I, L.L.C. ("AH EP LSV I") is the general partner of the AH LSV Fund I Entities and has sole voting and dispositive power with regard to the shares held by the AH LSV Fund I Entities. The managing members of AH EP LSV I are Marc Andreessen and Benjamin Horowitz. Marc Andreessen and Benjamin Horowitz share voting and dispositive power with respect to the shares held by the AH LSV Fund I Entities. |
Remarks: |
Exhibit 24 Power of Attorney |
/s/ Bradley Libuit, Attorney-in-fact | 09/18/2023 | |
** 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. |