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 of Derivative Security: 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-1 Preferred Stock
|
Â
(1)
|
Â
(1)
|
Common Stock
|
35,215
(5)
|
$
(1)
|
D
|
Â
|
Series B Preferred Stock
|
Â
(1)
|
Â
(1)
|
Common Stock
|
21,027
(5)
|
$
(1)
|
D
|
Â
|
Convertible Promissory Notes
|
Â
(2)
|
Â
(2)
|
Common Stock
|
14,903
(3)
(5)
|
$
(2)
|
D
|
Â
|
Warrants
|
Â
(4)
|
Â
(4)
|
Series B Preferred Stock
(1)
|
2,874
(4)
(5)
|
$
11
|
D
|
Â
|
* |
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). |
(1) |
All outstanding shares of the Issuer's preferred stock will automatically convert into Common Stock upon the closing of the Issuer's initial public offering (the "IPO"), for no additional consideration. |
(2) |
All Convertible Promissory Notes, plus interest accrued thereon, will automatically convert into Common Stock upon the closing of the IPO, at the IPO price. |
(3) |
Assumes IPO price of $4.00 per share of Common Stock and IPO closing on or about November 29, 2010. |
(4) |
Warrants are fully exercisable and will expire if not exercised in the IPO. If exercised upon closing of the IPO the Warrants will be net exercised, and therefore the number of shares of Common Stock issued to the Reporting Person will be adjusted in accordance with such net exercise. |
(5) |
Share numbers reflect the 1-for-10 reverse split of the Common Stock effective immediately prior to the IPO. |