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) 07/18/2019 | 3. Issuer Name and Ticker or Trading Symbol Medallia, Inc. [ MDLA ] | |||||||||||||
| 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) |
| Class A Common Stock(1) | 1,425 | I | Denarvor, L.L.C.(2) |
| 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 | (3) | (3) | Class A Common Stock(1) | 1,638,950 | (3) | I | SC US GF V Holdings, Ltd.(4) |
| Series B Convertible Preferred Stock | (5) | (5) | Class A Common Stock(1) | 17,622,476 | (5) | I | SC US GF V Holdings, Ltd.(4) |
| Series C Convertible Preferred Stock | (6) | (6) | Class A Common Stock(1) | 5,965,519 | (6) | I | SC US GF V Holdings, Ltd.(4) |
| Series D Convertible Preferred Stock | (7) | (7) | Class A Common Stock(1) | 8,858,605 | (7) | I | Sequoia Capital U.S. Growth Fund VI, L.P.(8) |
| Series D Convertible Preferred Stock | (7) | (7) | Class A Common Stock(1) | 443,721 | (7) | I | Sequoia Capital U.S. Growth VI Principals Fund, L.P.(8) |
| Series E Convertible Preferred Stock | (9) | (9) | Class A Common Stock(1) | 855,147 | (9) | I | Sequoia Capital U.S. Growth Fund VI, L.P.(8) |
| Series E Convertible Preferred Stock | (9) | (9) | Class A Common Stock(1) | 42,834 | (9) | I | Sequoia Capital U.S. Growth VI Principals Fund, L.P.(8) |
| Series E Convertible Preferred Stock | (9) | (9) | Class A Common Stock(1) | 8,726,574 | (9) | I | Sequoia Capital Global Growth Fund, LP(10)(11) |
| Series E Convertible Preferred Stock | (9) | (9) | Class A Common Stock(1) | 253,230 | (9) | I | Sequoia Capital Global Growth Principals Fund, LP(10)(11) |
1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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| Explanation of Responses: |
| 1. Each share of Class A Common Stock shall be reclassified into one share of Common Stock immediately prior to the completion of the Issuer's initial public offering of Common Stock and following the conversion of each series of the Issuer's Convertible Preferred Stock and the Issuer's Class B Common Stock into Class A Common Stock. |
| 2. SC US SSF 2013 (TTGP), L.L.C. is the general partner of SC U.S. Scout Seed Fund 2013 Management, L.P., which is the general partner of Sequoia Capital U.S. Scout Seed Fund 2013, L.P., which wholly owns Sequoia Capital U.S. Scout Fund IV, L.L.C., which in turn wholly owns Denarvor, L.L.C. As a result, SC US SSF 2013 (TTGP), L.L.C. and SC U.S. Scout Seed Fund 2013 Management, L.P. may be deemed to share voting and dispositive power with respect to the shares held by Denarvor, L.L.C. Each of SC US SSF 2013 (TTGP), L.L.C. and SC U.S. Scout Seed Fund 2013 Management, L.P. disclaims beneficial ownership of the securities held by Denarvor, L.L.C. except to the extent of its pecuniary interest therein, and the inclusion of these securities in this report shall not be deemed an admission of beneficial ownership of the reported securities for purposes of Section 16 or for any other purposes. |
| 3. Each share of Series A Convertible Preferred Stock shall automatically convert into Class A Common Stock on a 1:1 basis immediately prior to the closing of the Issuer's initial public offering of Common Stock and has no expiration date. |
| 4. SC US (TTGP), Ltd. is the general partner of SCGF V Management, L.P., which is the general partner of Sequoia Capital U.S. Growth Fund V, LP and Sequoia Capital USGF Principals Fund V, L.P., or collectively, the SC US GF V Funds, which together own 100% of the outstanding shares of SC US GF V Holdings, Ltd. As a result, SC US (TTGP), Ltd. and SCGF V Management, L.P. may be deemed to share voting and dispositive power with respect to the shares held by SC US GF V Holdings, Ltd. Each of SC US (TTGP), Ltd. and SCGF V Management, L.P. disclaims beneficial ownership of the securities held by SC US GF V Holdings, Ltd. except to the extent of its pecuniary interest therein, and the inclusion of these securities in this report shall not be deemed an admission of beneficial ownership of the reported securities for purposes of Section 16 or for any other purposes. |
| 5. Each share of Series B Convertible Preferred Stock shall automatically convert into Class A Common Stock on a 1:1 basis immediately prior to the closing of the Issuer's initial public offering of Common Stock and has no expiration date. |
| 6. Each share of Series C Convertible Preferred Stock shall automatically convert into Class A Common Stock on a 1:1 basis immediately prior to the closing of the Issuer's initial public offering of Common Stock and has no expiration date. |
| 7. Each share of Series D Convertible Preferred Stock shall automatically convert into Class A Common Stock on a 1:1 basis immediately prior to the closing of the Issuer's initial public offering of Common Stock and has no expiration date. |
| 8. SC US (TTGP), Ltd. is the general partner of SC U.S. Growth VI Management, L.P., which is the general partner of Sequoia Capital U.S. Growth Fund VI, L.P. and Sequoia Capital U.S. Growth VI Principals Fund, L.P. As a result, SC US (TTGP), Ltd. and SC U.S. Growth VI Management, L.P. may be deemed to share voting and dispositive power with respect to the shares held by Sequoia Capital U.S. Growth Fund VI, L.P. and Sequoia Capital U.S. Growth VI Principals Fund, L.P. Each of SC US (TTGP), Ltd. and SC U.S. Growth VI Management, L.P. disclaims beneficial ownership of the securities held by Sequoia Capital U.S. Growth Fund VI, L.P. and Sequoia Capital U.S. Growth VI Principals Fund, L.P. except to the extent of its pecuniary interest therein, and the inclusion of these securities in this report shall not be deemed an admission of beneficial ownership of the reported securities for purposes of Section 16 or for any other purposes. |
| 9. Each share of Series E Convertible Preferred Stock shall automatically convert into Class A Common Stock on a 1:1 basis immediately prior to the closing of the Issuer's initial public offering of Common Stock and has no expiration date. |
| 10. SC US (TTGP), Ltd. is the general partner of SCGGF Management, L.P., which is the general partner of Sequoia Capital Global Growth Fund, LP and Sequoia Capital Global Growth Principals Fund, LP. As a result, SC US (TTGP), Ltd. and SCGGF Management, L.P. may be deemed to share voting and dispositive power with respect to the shares held by Sequoia Capital Global Growth Fund, LP and Sequoia Capital Global Growth Principals Fund, LP. |
| 11. (Continued from Footnote 10) Voting and disposition decisions at SC US (TTGP), Ltd. with respect to the shares held by the SC GGF Funds are made by an investment committee consisting of Messrs. Douglas Leone and James J. Goetz. Each of SC US (TTGP), Ltd., SCGGF Management, L.P., Mr. Leone and Mr. Goetz disclaims beneficial ownership of the securities held by Sequoia Capital Global Growth Fund, LP and Sequoia Capital Global Growth Principals Fund, LP except to the extent of its pecuniary interest therein, and the inclusion of these securities in this report shall not be deemed an admission of beneficial ownership of the reported securities for purposes of Section 16 or for any other purposes. |
| Remarks: |
| Form 1 of 2. /s/ Jung Yeon Son, by PoA for Douglas Leone, a Director of SC US (TTGP), Ltd., GP of SCGF V Management, L.P., GP of Sequoia Capital U.S. Growth Fund V, L.P. and Sequoia Capital USGF Principals Fund V, L.P., which together own 100% of SC US GF V Holdings, Ltd |
| /s/ Jung Yeon Son, by power of attorney for James Goetz, a Director of SC US (TTGP), Ltd. | 07/18/2019 | |
| /s/ Jung Yeon Son, by power of attorney for Douglas Leone, a Director of SC US (TTGP), Ltd., the general partner of SC U.S. Growth VI Management, L.P., SCGF V Management, L.P. and SCGGF Management, L.P. | 07/18/2019 | |
| /s/ Jung Yeon Son, by PoA for Douglas Leone, a Director of SC US (TTGP), Ltd., GP of SC U.S. Growth VI Management, L.P., GP of Sequoia Capital U.S. Growth Fund VI, L.P. and Sequoia Capital U.S. Growth VI Principals Fund, L.P. | 07/18/2019 | |
| /s/ Jung Yeon Son, by power of attorney for Douglas Leone, a Director of SC US (TTGP), Ltd., the general partner of SCGF V Management, L.P., the general partner of Sequoia Capital U.S. Growth Fund V, L.P. and Sequoia Capital USGF Principals Fund V, L.P. | 07/18/2019 | |
| See Remarks | 07/18/2019 | |
| ** 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. | ||