SEC Form 4 · accession 0001209191-18-055697

SI-BONE, Inc. · SIBN

Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗

Reporting owner

John Gordon Freund

Director · 10% Owner

Period of report

Oct 19, 2018

Accepted (ET)

Oct 19, 2018 · 4:48 pm EDT

Rule 10b5-1 plan

unknown — predates the checkbox

Issuer CIK

0001459839

Table I — non-derivative securities

Security	Date	Code	Shares	Price	A/D	Owned after	D/I	Nature of ownership
Common Stock^F1,F2	Oct 19, 2018	C	2,213,425	—	A	2,213,425	I	By Skyline Venture Partners V, L.P.
Common Stock^F3,F2	Oct 19, 2018	C	792,195	—	A	3,005,620	I	By Skyline Venture Partners V, L.P.
Common Stock^F1,F2	Oct 19, 2018	C	690,689	—	A	3,696,309	I	By Skyline Venture Partners V, L.P.
Common Stock^F1,F2	Oct 19, 2018	C	398,676	—	A	4,094,985	I	By Skyline Venture Partners V, L.P.
Common Stock^F2	Oct 19, 2018	P	325,000	$15.00	A	4,419,985	I	By Skyline Venture Partners V, L.P.

Table II — derivative securities

Security	Conv. / exercise price	Date	Code	Shares	A/D	Exercisable	Expires	Underlying	Underlying shares	Owned after	D/I
Warrant (right to buy)^F2,F4	$9.10	Oct 19, 2018	X	39,421	D	—	—	Series 5 Preferred Stock	39,421	0	I
Series 5 Preferred Stock^F2,F1	$9.10	Oct 19, 2018	X	39,421	A	—	—	Common Stock	39,421	816,099	I
Series 5 Preferred Stock^F2,F1	—	Oct 19, 2018	S	23,904	D	—	—	Common Stock	23,904	792,195	I
Series 4 Preferred Stock^F1,F2	—	Oct 19, 2018	C	2,213,425	D	—	—	Common Stock	2,213,425	0	I
Series 5 Preferred Stock^F1,F2	—	Oct 19, 2018	C	792,195	D	—	—	Common Stock	792,195	0	I
Series 6 Preferred Stock^F3,F2	—	Oct 19, 2018	C	652,347	D	—	—	Common Stock	690,689	0	I
Series 7 Preferred Stock^F1,F2	—	Oct 19, 2018	C	398,676	D	—	—	Common Stock	398,676	0	I

Explanation of responses

F1The Issuer's Series 4 Preferred Stock, Series 5 Preferred Stock and Series 7 Preferred Stock automatically converted 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.
F2Shares 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. Dr. 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 disclaims beneficial ownership of such securities, except to the extent of his pecuniary interest therein.
F3The Issuer's Series 6 Preferred Stock automatically converted 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.
F4Shares subject to the warrant are immediately exercisable. The warrant will expire in connection with the closing of the Issuer's initial public offering.
F5Immediately prior to the closing of the Issuer's initial public offering, SVP V exercised a warrant to purchase 39,421 shares of Series 5 Preferred Stock at an exercise price of $9.10 per share. The exercise price was paid on a net exercise cashless basis calculated using the Issuer's initial public offering price of $15.00, resulting in the Issuer withholding 23,904 of the warrant shares to pay the exercise price and issuing SVP V the remaining 15,517 shares.