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 |
Convertible Promissory Note
|
(1)
|
(1)
|
Common Stock
|
19,465
|
$
(1)
|
I
|
See Footnote
(3)
|
Convertible Promissory Note
|
(2)
|
(2)
|
Common Stock
|
9,732
|
$
(2)
|
I
|
See Footnote
(4)
|
Stock option (right to buy)
|
(5)
|
01/10/2029 |
Common Stock
|
9,849
|
$
0.0003
|
D
|
|
Common Stock warrant (right to buy)
|
(6)
|
02/11/2023 |
Common Stock
|
1,455
|
$
2.75
|
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) |
Represents $81,753.00 of outstanding principal and interest calculated through November 10, 2021. The note will convert into 19,465 shares of Common Stock upon the closing of the Issuer's initial public offering of Common Stock (the "IPO"). |
(2) |
Represents $40,874.40 of outstanding principal and interest calculated through November 10, 2021. The note will convert into 9,732 shares of Common Stock upon the closing of the IPO. |
(3) |
The Convertible Promissory Note is held by the R and S Brounstein Living Trust, of which the Reporting Person is a trustee. |
(4) |
The Convertible Promissory Note is held by CTRLCFO, LLC, of which the Reporting Person is the Manager. |
(5) |
One thirteeth of the shares subject to the option vest on each one-month anniversary beginning December 2, 2021 and each one-month anniversary thereafter, subject to the Reporting Person continuing as a service provider through each such date. |
(6) |
All of the shares subject to the warrant are fully vested and exercisable as of the date hereof. |