SEC FORM
4
SEC Form 4
| FORM 4 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934
or Section 30(h) of the Investment Company Act of 1940
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| OMB Number: |
3235-0287 |
| Estimated average burden |
| hours per response: |
0.5 |
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b). |
1. Name and Address of Reporting Person*
| C/O TANDEM DIABETES CARE, INC. |
| 11075 ROSELLE STREET |
(Street)
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2. Issuer Name and Ticker or Trading Symbol
TANDEM DIABETES CARE INC
[ TNDM ]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
| X |
Director |
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10% Owner |
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Officer (give title below) |
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Other (specify below) |
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3. Date of Earliest Transaction
(Month/Day/Year)
06/14/2018
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4. If Amendment, Date of Original Filed
(Month/Day/Year)
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6. Individual or Joint/Group Filing (Check Applicable Line)
| X |
Form filed by One Reporting Person |
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Form filed by More than One Reporting Person |
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| Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned |
|---|
| 1. Title of Security (Instr.
3)
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2. Transaction Date
(Month/Day/Year) |
2A. Deemed Execution Date, if any
(Month/Day/Year) |
3. Transaction Code (Instr.
8)
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4. Securities Acquired (A) or Disposed Of (D) (Instr.
3, 4 and 5)
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5.
Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr.
3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr.
4)
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7. Nature of Indirect Beneficial Ownership (Instr.
4)
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| Code |
V |
Amount |
(A) or (D) |
Price |
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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|---|
| 1. Title of Derivative Security (Instr.
3)
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2. Conversion or Exercise Price of Derivative Security
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3. Transaction Date
(Month/Day/Year) |
3A. Deemed Execution Date, if any
(Month/Day/Year) |
4. Transaction Code (Instr.
8)
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5.
Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr.
3, 4 and 5)
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6. Date Exercisable and Expiration Date
(Month/Day/Year) |
7. Title and Amount of Securities Underlying Derivative Security (Instr.
3 and 4)
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8. Price of Derivative Security (Instr.
5)
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9.
Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr.
4)
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10. Ownership Form: Direct (D) or Indirect (I) (Instr.
4)
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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 |
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Stock Options
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$18.86
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06/14/2018 |
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A |
|
50,000 |
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|
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Common Stock |
50,000 |
$0.00
|
50,000 |
D |
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| Explanation of Responses: |
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| Remarks: |
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/s/ Leigh A. Vosseller, Attorney-in-Fact for Richard P. Valencia |
06/18/2018 |
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** Signature of Reporting Person |
Date |
| Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. |
| * 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). |
| Note: File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure. |
| 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 Number. |
LIMITED POWER OF ATTORNEY FOR
SECTION 16 REPORTING OBLIGATIONS
The undersigned hereby constitutes and appoints David B. Berger, Leigh Vosseller
and Bruce Feuchter, or either of them signing individually, the undersigned's
true and lawful attorney-in-fact (each, an " Attorney-in-Fact" ) to:
{l)complete and execute, for and on behalf of the undersigned, in the
undersigned's capacity as an officer, director and/or beneficial owner of more
than ten percent (10%) of any equity securities of Tandem Diabetes, Inc., a
Delaware corporation (the "Company"), Forms 3, 4 and 5, and Schedules 13D and
13G, and such other forms and documents, including any amendments to any of the
foregoing, as such Attorney-In-Fact shall in his or her discretion determine to
be required or advisable pursuant to Section 16(a) and Section 13(d) of the
Securities Exchange Act of 1934, as amended (the "Exchange Act") and the rules
and regulations promulgated thereunder, or any successor laws and regulations,
as a consequence of, or in respect of, the undersigned's ownership, acquisition
or disposition of securities of the Company;
(2)do and perform any and all acts for and on behalf of the undersigned which
may be necessary or desirable to complete and execute any such forms and
schedules , including any amendments thereto, and timely file such forms and
schedules, including any amendments thereto, with the United States Securities
and Exchange Commission (the "SEC"), and any securities exchange or similar
authority; and
(3)take any other action of any type whatsoever in connection with the foregoing
which, in the opinion of such Attorney-in-Fact, may be of benefit to, in the
best interest of, or legally required by, the undersigned, it being understood
that the documents executed by such Attorney-in-Fact on behalf of the
undersigned pursuant to this Power of Attorney shall be in such form and shall
contain such information as such Attorney-in-Fact may approve in such
Attorney-in-Fact's discretion.
The undersigned hereby grants to each such Attorney-in-Fact full power and
authority to do and perform each and every act and thing whatsoever requisite,
necessary or proper to be done in the exercise of any of the rights and powers
herein granted, as fully to all intents and purposes as the undersigned might or
could do if personally present, with full power of substitution and revocation,
hereby ratifying and confirming all that each such Attorney-in-Fact, or each
such Attorney-in-Fact's substitute or substitutes, shall lawfully do or cause to
be done by virtue of this power of attorney and the rights and powers herein
granted. The undersigned acknowledges that each of the foregoing
Attorneys-in-Fact, in serving in such capacity at the request of the
undersigned, are not assuming, nor is the Company assuming, any of the
undersigned's responsibilities to comply with Section 16(a) and Section 13(d) of
the Exchange Act.
The undersigned agrees that each such Attorney-in-Fact may rely entirely on
information furnished orally or in writing by the undersigned to each such
Attorney-in-Fact. The undersigned also agrees to indemnify and hold harmless
the Company and each such Attorney-in-Fact against any losses, claims, damages
or liabilities (or actions in these respects) that arise out of or are based on
any untrue statement or omission of necessary facts in the information provided
by the undersigned to such Attorney-in-Fact for purposes of executing,
acknowledging, delivering and filing Forms 3, 4 and 5, and Schedules 13D and
13G, including any amendments thereto, and agrees to reimburse the Company and
each such Attorney-in-Fact for any legal or other expenses reasonably incurred
in connection with investigating or defending against any such loss, claim,
damage, liability or action.
This Power of Attorney shall remain in full force and effect until the
undersigned is no longer required to file Forms 3, 4 and 5, or Schedules 13D and
13G, with respect to the undersigned's holdings of and transactions in
securities issued by the Company, unless earlier revoked by the undersigned in a
signed writing delivered to the foregoing Attorneys-in-Fact.
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be
executed as of this 7th day of June, 2018
/s/ Richard P. Valencia
