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 Convertible Preferred Stock
|
Â
(3)
|
Â
(3)
|
Common Stock
|
16,355
|
$
(3)
|
I
|
See footnote
(4)
|
Series D Convertible Preferred Stock
|
Â
(5)
|
Â
(5)
|
Common Stock
|
186,011
|
$
(5)
|
I
|
See footnote
(6)
|
Series E Convertible Preferred Stock
|
Â
(7)
|
Â
(7)
|
Common Stock
|
981,977
|
$
(7)
|
I
|
See footnote
(6)
|
Series G Convertible Preferred Stock
|
Â
(8)
|
Â
(8)
|
Common Stock
|
46,296
|
$
(8)
|
I
|
See footnote
(6)
|
Non-qualified stock option (right to buy)
|
Â
(9)
|
08/08/2016 |
Common Stock
|
137,500
|
$
2
|
D
|
Â
|
Employee stock option (right to buy)
|
Â
(9)
|
08/08/2016 |
Common Stock
|
50,000
|
$
2
|
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) |
Shares held directly by SEI Private Trust Company, Trustee of the Welch Family Heritage Trust I u/l dated 9/24/01. |
(2) |
Shares held directly by Welch Group, L.P. of which the Reporting Person is the general partner. |
(3) |
The Series A Convertible Preferred Stock shall automatically convert into Common Stock on a 1:1.033 basis immediately prior to the closing of the Issuer's initial public offering of common stock. |
(4) |
Shares held directly by the Welch Family Trust, dated 4/3/96 for which the Reporting Person serves as trustee. |
(5) |
The Series D Convertible Preferred Stock shall automatically convert into Common Stock on a one-for-one basis immediately prior to the closing of the Issuer's initial public offering of common stock. |
(6) |
Shares held directly by LRFA, LLC of which the Reporting Person is the sole managing member. |
(7) |
The Series E Convertible Preferred Stock shall automatically convert into Common Stock on a one-for-one basis immediately prior to the closing of the Issuer's initial public offering of common stock. |
(8) |
The Series G Convertible Preferred Stock shall automatically convert into Common Stock on a one-for-one basis immediately prior to the closing of the Issuer's initial public offering of common stock. |
(9) |
The option is subject to an early exercise provision and is immediately exercisable. One forty-eighth of the shares subject to the option vested on July 29, 2006 and one forty-eighth of the shares shall vest monthly thereafter. |