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 |
Senior Secured Convertible Promissory Note
|
(1)
|
(2)
|
Common Stock
|
29,124
(12)
|
$
(4)
(11)
|
D
|
|
Senior Secured Convertible Promissory Note
|
(1)
|
(2)
|
Common Stock
|
472,196
(12)
|
$
(4)
(11)
|
D
|
|
Senior Secured Convertible Promissory Note
|
(1)
|
(3)
|
Common Stock
|
79,361
(12)
|
$
(4)
(11)
|
D
|
|
Warrant to Purchase Common Stock
|
(5)
|
(7)
|
Common Stock
|
28,767
|
$
(9)
(11)
|
D
|
|
Warrant to Purchase Common Stock
|
(5)
|
(7)
|
Common Stock
|
233,728
|
$
(9)
(11)
|
D
|
|
Warrant to Purchase Common Stock
|
(6)
|
(8)
|
Common Stock
|
39,554
|
$
(10)
(11)
|
D
|
|
* |
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) |
The senior secured convertible promissory note (the "Note") must be converted in conjunction with the Company's initial public offering. The Note may be converted prior to the Company's initial public offering on a change of control or at the election of the holder. |
(2) |
The Note must be paid in full at the earlier of (i) January 6, 2014, (ii) the occurrence of an Event of Default as defined in the Note or (iii) the closing of an initial public offering raising at least $10 million in gross proceeds ("IPO"). |
(3) |
The Note must be paid in full at the earlier of (i) July 29, 2014, (ii) the occurrence of an Event of Default as defined in the Note or (iii) the closing of an initial public offering raising at least $10 million in gross proceeds ("IPO"). |
(4) |
If the Note is converted in conjunction with an IPO, the conversion price will be equal to the lower of 0.70 times the IPO price or $3.48. If the holder elects to convert the Note prior to the IPO or the maturity date, the conversion price will be equal to the lower of 0.70 times the price per share paid by investors in the most recent Private Equity Financing (as defined in the Note) to occur prior to the Calendar Due Date or $3.48. |
(5) |
The warrant may be exercised prior to January 6, 2014 in conjunction with an IPO or a Private Equity Financing. Otherwise, the warrant may not be exercised prior to January 6, 2014. |
(6) |
The warrant may be exercised prior to July 29, 2014 in conjunction with an IPO or a Private Equity Financing. Otherwise, the warrant may not be exercised prior to July 29, 2014. |
(7) |
The warrant will expire on November 21, 2019 provided, however, if the Company completes an IPO after November 21, 2017 but prior to November 21, 2019, then the expiration date will be extended for an additional five years following the completion of the IPO. |
(8) |
The warrant will expire on July 29, 2020 provided, however, if the Company completes an IPO after July 29, 2018 but prior to July 29, 2020, then the expiration date will be extended for an additional five years following the completion of the IPO. |
(9) |
In the event an IPO is completed prior to January 6, 2014, the per-share exercise price will be equal to the lower of 0.70 times the IPO Price or $3.48. In the event of a Private Equity Financing that occurs prior to January 6, 2014, the per-share exercise price will equal the lower of 0.70 times the Private Equity Financing price or $3.48; provided, however, that (A) if the Company undertakes first, a Private Equity Financing and secondly, an IPO prior to January 6, 2014 and (B) the Private Equity Financing price is higher than the IPO price, then the per share exercise price will be adjusted to equal the exercise price calculated based on the IPO price. If the Company does not undertake a Private Equity Financing or an IPO prior to January 6, 2014, then the exercise price will be $3.48 per share. |
(10) |
In the event an IPO is completed prior to July 29, 2014, the per-share exercise price will be equal to the lower of 0.70 times the IPO Price or $3.48. In the event of a Private Equity Financing that occurs prior to July 29, 2014, the per-share exercise price will equal the lower of 0.70 times the Private Equity Financing price or $3.48; provided, however, that (A) if the Company undertakes first, a Private Equity Financing and secondly, an IPO prior to July 29, 2014 and (B) the Private Equity Financing price is higher than the IPO price, then the per share exercise price will be adjusted to equal the exercise price calculated based on the IPO price. If the Company does not undertake a Private Equity Financing or an IPO prior to July 29, 2014, then the exercise price will be $3.48 per share. |
(11) |
Reflects the reverse stock split effected on November 21, 2013. |
(12) |
Reflects interest accrued as of November 21, 2013. |