SEC Form 4 · accession 0001209191-18-055704

SI-BONE, Inc. · SIBN

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

Reporting owner

Director

Period of report

Oct 19, 2018

Accepted (ET)

Oct 19, 2018 · 4:58 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	1,495,036	—	A	1,495,036	I	By Arboretum Ventures IV, LP
Common Stock^F2	Oct 19, 2018	P	200,000	$15.00	A	1,695,036	I	By Arboretum Ventures IV, LP

Security	Conv. / exercise price	Date	Code	Shares	A/D	Exercisable	Expires	Underlying	Underlying shares	Owned after	D/I
Series 7 Preferred Stock^F1,F2	—	Oct 19, 2018	C	1,495,036	D	—	—	Common Stock	1,495,036	0	I

F1The Issuer's 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 Arboretum Ventures IV, LP ("AV IV"). Arboretum Investment Manager IV, LLC ("AIM IV") serves as the general partner of AV IV. Jan Garfinkle, Timothy B. Petersen, a member of the Issuer's board of directors, and Paul McCreadie are managing members of AIM IV and share voting and dispositive power with regard to these shares and therefore each of the foregoing managing members may be deemed to have the same powers with respect to such shares. Mr. Petersen disclaims beneficial ownership of such shares except to the extent of his proportionate pecuniary interest, if any.