SEC Form 4 · accession 0001192482-16-000722

Tabula Rasa HealthCare, Inc. · TRHC

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

Reporting owner

Michael J Gausling

10% Owner

Period of report

Oct 4, 2016

Accepted (ET)

Oct 5, 2016 · 4:24 pm EDT

Rule 10b5-1 plan

unknown — predates the checkbox

Issuer CIK

0001651561

Table I — non-derivative securities

Security	Date	Code	Shares	Price	A/D	Owned after	D/I	Nature of ownership
Common Stock^F1,F2,F3	Oct 4, 2016	C	1,516,070	—	A	1,636,888	I	By Originate Growth Fund #1A, L.P. and Originate Growth Fund #1Q, L.P.
Common Stock^F1,F2,F3	Oct 4, 2016	C	971,012	—	A	2,607,900	I	By Originate Growth Fund #1A, L.P. and Originate Growth Fund #1Q, L.P.
Common Stock^F1,F2,F3	Oct 4, 2016	C	172,967	—	A	2,780,867	I	By Originate Growth Fund #1A, L.P. and Originate Growth Fund #1Q, L.P.
Common Stock	Oct 4, 2016	P	8,000	$12.00	A	2,788,867	D

Table II — derivative securities

Security	Conv. / exercise price	Date	Code	Shares	A/D	Exercisable	Expires	Underlying	Underlying shares	D/I
Series A Preferred Stock^F1,F2,F3,F4	—	Oct 4, 2016	C	2,941,176	D	—	—	Common Stock	1,516,070	I
Series A-1 Preferred Stock^F1,F2,F3,F4	—	Oct 4, 2016	C	1,883,763	D	—	—	Common Stock	971,012	I
Series B Preferred Stock^F1,F2,F3,F4	—	Oct 4, 2016	C	335,557	D	—	—	Common Stock	172,967	I

Explanation of responses

F1The shares consist of (a) 472,560 shares of common stock issued upon the conversion of 916,766 shares of Series A preferred stock held by Originate Growth Fund #1A, L.P., ("Originate #1A"), (b) 1,043,510 shares of common stock issued upon the conversion of 2,024,410 shares of Series A preferred stock held by Originate Growth Fund #1Q, L.P., ("Originate #1Q"), (c) 302,659 shares of common stock issued upon the conversion of 587,158 shares of Series A-1 preferred stock held by Originate #1A, (d) 668,353 shares of common stock issued upon the conversion of 1,296,605 shares of Series A-1 preferred stock held by Originate #1Q, (e) 53,912 shares of common stock issued upon the conversion of 104,589 shares of Series B preferred stock held by Originate #1A, (f) 119,055 shares of common stock issued upon the conversion of 230,968 shares of Series B preferred stock held by Originate #1Q, (g) 37,658 shares of common stock held by Originate #1A, (CONTINUED IN FOOTNOTE 2)
F2and (h) 83,160 shares of common stock held by Originate #1Q.
F3The general partner of both Originate #1Q and Originate #1A is Originate GP, LLC, a limited liability company. The members of Originate GP, LLC are Glen Bressner, Eric Arnson, and Michael Gausling. The members of Originate GP share voting and dispositive power over the shares held by Originate #1Q and Originate #1A. Mr. Gausling disclaims beneficial ownership of such shares, except to the extent of his pecuniary interest.
F4All series of Preferred Stock automatically converted into Tabula Rasa HealthCare, Inc. (the "Issuer") common stock immediately prior to the closing of the initial public offering and have no expiration date.