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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 A Preferred Stock | (1) | 07/02/2010 | 07/02/2010 | C | 4,880,343 | (1) | (1) | Common Stock | 1,626,781 | (1) | 0 | I | By Trust | ||
Series B Preferred Stock | (1) | 07/02/2010 | 07/02/2010 | C | 12,162,167 | (1) | (1) | Common Stock | 4,054,053 | (1) | 0 | I | By Trust | ||
Series C Preferred Stock | (2) | 07/02/2010 | 07/02/2010 | C | 10,572,687 | (1) | (1) | Common Stock | 3,700,575 | (1) | 0 | I | By Trust | ||
Series D Preferred Stock | (1) | 07/02/2010 | 07/02/2010 | C | 4,097,877 | (1) | (1) | Common Stock | 1,365,959 | (1) | 0 | I | By Trust | ||
Series E Preferred Stock | (1) | 07/02/2010 | 07/02/2010 | C | 40,825,647 | (1) | (1) | Common Stock | 13,608,549 | (1) | 0 | I | By Trust | ||
Series C Warrants (right to buy) | (3) | 07/02/2010 | 07/02/2010 | X | 325,441 | (3) | (3) | Common Stock | 113,908 | (3) | 0 | I | By Trust |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Musk Elon C/O TESLA MOTORS, INC. 3500 DEER CREEK ROAD PALO ALTO, CA 94304 |
X | X | Pres,Prod Architect & Director |
/s/ Elon Musk | 07/02/2010 | |
**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) | Each share of the Issuer's Series A preferred stock, Series B preferred stock, Series D preferred stock and Series E preferred stock automatically converted to .333333 of a share common stock upon the closing of the Issuer's initial public offering and has no expiration date. |
(2) | Each share of the Issuer's Series C preferred stock automatically converted into .350013 of a share of common stock upon the closing the Issuer's initial public offering, and has no expiration date. |
(3) | The warrant was automatically net exercised by the reporting person on the effective date of Issuer's initial public offering. |