Jennifer Ernst - 12 Nov 2021 Form 4 Insider Report for Tivic Health Systems, Inc. (TIVC)

Role
Chief Executive Officer, Director, 10%+ Owner
Signature
/s/ Jennifer Ernst
Issuer symbol
TIVC
Transactions as of
12 Nov 2021
Net transactions value
-$101,200
Form type
4
Filing time
15 Nov 2021, 20:11:31 UTC
Previous filing
10 Nov 2021
Next filing
08 Feb 2022
SEC
View on sec.gov

Transactions Table

Type Sym Class Transaction Value $ Shares Change % * Price $ Shares After Date Ownership Footnotes
transaction TIVC Common Stock Conversion of derivative security $0 +1,391 +0.12% $0.000000 1,172,891 12 Nov 2021 Direct F1
transaction TIVC Common Stock Conversion of derivative security $0 +26,986 +2.3% $0.000000 1,199,877 12 Nov 2021 Direct F2

Derivative Securities (e.g., puts, calls, warrants, options, convertible securities)

Type Sym Class Transaction Value $ Shares Change % * Price $ Shares After Date Underlying Class Amount Exercise Price Ownership Footnotes
transaction TIVC Series Seed-2 Convertible Preferred Stock Conversion of derivative security $0 -5,566 -100% $0.000000* 0 12 Nov 2021 Common Stock 1,391 Direct F1
transaction TIVC Convertible Promissory Note Conversion of derivative security $101,200 0 12 Nov 2021 Common Stock 26,986 $3.75 Direct F2, F3
* An asterisk sign (*) next to the price indicates that the price is likely invalid.

Explanation of Responses:

Id Content
F1 The shares 5,566 shares of Series Seed-2 Convertible Preferred Stock held by the Reporting Person automatically converted into 1,391 shares of the Issuer's common stock on November 12, 2021 in connection with the Issuer's initial public offering (the "IPO"). The Series Seed-2 Convertible Preferred Stock had no expiration date.
F2 On November 12, 2021, in connection with the Issuer's IPO, the outstanding principal and accrued but unpaid interest of the Convertible Promissory Note (the "Note"), amounting to $100,000 and $1,200, respectively, automatically converted into an aggregate of 26,986 shares of the Issuer's common stock at a conversion price of $3.75 per share, which conversion price was equal to the IPO price per share of the issuer's common stock, less a 25% discount.
F3 The Note was scheduled to mature on June 1, 2023.