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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | |||
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB control number. | SEC 1474 (9-02) |
1. Title of Derivative Security (Instr. 3) |
2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) |
5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4, and 5) |
6. Date Exercisable and Expiration Date (Month/Day/Year) |
7. Title and Amount of Underlying Securities (Instr. 3 and 4) |
8. Price of Derivative Security (Instr. 5) |
9. Number of Derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) |
10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
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Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Mosaic Venture Partners II Limited Partnership 6300 NORTHAM DRIVE MISSISSAUGA, ONTARIO, A6 L4V 1H7 |
X | |||
Samuel David G. C/O BIRCH HILL EQUITY PARTNERS 100 WELLINGTON ST, W. SUITE 2300, PO BOX 22 TORONTO, ONTARIO, A6 M5K 1A1 |
X | |||
1369904 Ontario, Inc. C/O MOSAIC VENTURE PARTNERS II, L.P. 6300 NORTHAM DRIVE MISSISSAUGA, ONTARIO, A6 L4V 1H7 |
X | |||
Lobo Vernon F C/O MOSAIC VENTURE PARTNERS II, L.P. 6300 NORTHAM DRIVE MISSISSAUGA, ONTARIO, A6 L4V 1H7 |
X |
/s/ Vernon Lobo, authorized signatory of 1369904 Ontario Inc., the general partner of the Reporting Person | 10/31/2014 | |
**Signature of Reporting Person | Date | |
/s/ Frances Dea, attorney-in-fact | 10/31/2014 | |
**Signature of Reporting Person | Date | |
/s/ Vernon Lobo, authorized signatory of the Reporting Owner | 10/31/2014 | |
**Signature of Reporting Person | Date | |
/s/ Vernon Lobo | 10/31/2014 | |
**Signature of Reporting Person | Date |
* | If the form is filed by more than one reporting person, see Instruction 4(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) | Mosaic Venture Partners II, Limited Partnership ("Mosaic") was the record owner of these shares. 1369904 Ontario, Inc. ("Ontario"), as the general partner of Mosaic, had voting and investment control of the shares held by Mosaic. David Samuel and Vernon Lobo are Managing Directors of Ontario and may have been deemed to share voting and investment power with respect to the shares held by Mosaic. Mr. Samuel and Mr. Lobo disclaimed beneficial ownership of all shares held by Mosaic except to the extent of their pecuniary interest therein. |
Remarks: Five9, Inc. shares were distributed out to various partners by Mosaic Venture Partners II Limited Partnership |