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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 | ||||||||
Series B Preferred Stock | (3) | 04/20/2011 | C | 66,666 | (5) | (6) | Common Stock | 66,666 (3) | $ 0 | 0 | I | See Footnote (1) | |||
Series D Preferred Stock | (3) | 04/20/2011 | C | 13,661 | (5) | (6) | Common Stock | 13,661 (3) | $ 0 | 0 | I | See Footnote (2) | |||
Series E Preferred Stock | (3) | 04/20/2011 | C | 21,192 | (5) | (6) | Common Stock | 21,192 (3) | $ 0 | 0 | I | See Footnote (2) | |||
Series F Preferred Stock | (3) | 04/20/2011 | C | 8,513 | (5) | (6) | Common Stock | 8,513 (3) | $ 0 | 0 | I | See Footnote (2) | |||
Warrant to Purchase Common Stock | $ 3 | 04/20/2011 | X | 887 | (7) | 07/13/2011 | Common Stock | 887 | $ 0 | 0 | I | See Footnote (2) | |||
Warrant to Purchase Common Stock | $ 3 | 04/20/2011 | X | 887 | (7) | 08/09/2011 | Common Stock | 887 | $ 0 | 0 | I | See Footnote (2) | |||
Warrant to Purchase Common Stock | $ 3 | 04/20/2011 | X | 2,393 | (7) | 10/01/2011 | Common Stock | 2,393 | $ 0 | 0 | I | See Footnote (2) |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Schultz Frank C/O ELLIE MAE, INC. 4155 HOPYARD ROAD, SUITE 200 PLEASANTON, CA 94588 |
X |
/s/ LeeAnn Linck, Attorney-in-Fact for Frank J. Schultz | 04/20/2011 | |
**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) | These shares are held by the Frank J. and Paula C. Schultz 1989 Revocable Trust dated May 12, 1989. |
(2) | These securities are held by Charles Schwab & Co. Inc. Custodian FBO Frank J. Schultz Roth Contributory IRA. |
(3) | Each share of Series B, Series D, Series E and Series F Preferred Stock automatically converted on a 1-for-1 basis into common stock upon the closing of the Issuer's initial public offering. |
(4) | On April 20, 2011, the reporting person exercised warrants to purchase an aggregate of 4,167 shares of common stock for $3.00 per share. The reporting person paid the warrant exercise price on a cashless basis, resulting in the withholding by the Issuer of 2,084 shares of common stock to pay the warrant exercise price, while the remaining 2,083 shares of common stock were issued to the reporting person. |
(5) | The shares are immediately convertible. |
(6) | The shares do not have an expiration date. |
(7) | This warrant is immediately exercisable. |