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 APPROVAL |
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 DELPHI VENTURES, |
3000 SAND HILL RD., BLDG. 1, STE. 135 |
(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 |
X |
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) 11/19/2013
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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 |
Common Stock |
11/19/2013 |
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C |
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3,632,552 |
A |
$0.00
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3,632,552 |
I |
Directly owned by Delphi Ventures VIII, L.P.
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Common Stock |
11/19/2013 |
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C |
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35,467 |
A |
$0.00
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35,467 |
I |
Directly owned by Delphi BioInvestments VIII, L.P.
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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 |
Series C Preferred Stock |
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11/19/2013 |
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C |
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1,113,545
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Common Stock |
664,565
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$0.00
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0 |
I |
Directly owned by Delphi Ventures VIII, L.P.
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Series C Preferred Stock |
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11/19/2013 |
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C |
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10,871
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Common Stock |
6,488
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$0.00
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0 |
I |
Directly owned by Delphi BioInvestments VIII, L.P.
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Series D Preferred Stock |
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11/19/2013 |
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C |
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4,973,160 |
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Common Stock |
2,967,987
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$0.00
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0 |
I |
Directly owned by Delphi Ventures VIII, L.P.
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Series D Preferred Stock |
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11/19/2013 |
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C |
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48,558 |
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Common Stock |
28,979
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$0.00
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0 |
I |
Directly owned by Delphi BioInvestments VIII, L.P.
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Explanation of Responses: |
Remarks: |
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/s/ Matthew T. Potter, by power of attorney for Douglas A. Roeder |
11/21/2013 |
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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. |
POWER OF ATTORNEY
Each of the undersigned entities and individuals (each, a "Reporting Person")
hereby constitutes and appoints MATTHEW T. POTTER his, her or its true and
lawful attorney-in-fact (the "Attorney-in-Fact") to:
(1) Prepare, execute in the Reporting Persons' names and on the Reporting
Persons' behalves, and submit to the U.S. Securities and Exchange Commission
(the "SEC") a Form ID, including amendments thereto, and any other documents
necessary or appropriate to obtain codes and passwords enabling such Reporting
Person to make electronic filings with the SEC of Reports required by Section
16(a) of the Securities Exchange Act of 1934 or any rule or regulation of the
SEC;
(2) Prepare, execute and file on behalf of such Reporting Person individually,
or jointly together with the other Reporting Persons, any and all reports,
notices, communications and other documents (including, but not limited to,
reports on Schedule 13D, Schedule 13G, Form 13F, Form 3, Form 4 and Form 5) that
such Reporting Person may be required to file with the SEC pursuant to the
Securities Act of 1933, as amended (together with the implementing regulations
thereto, the "Act") and the Securities Exchange Act of 1934, as amended
(together with the implementing regulations thereto, the "Exchange Act")
(collectively, the "Reports") with respect to each Reporting Person's (a) status
as an officer or director of, or (b) ownership of, or transactions in,
securities of, any entity whose securities are beneficially owned (directly or
indirectly) by such Reporting Person (collectively, the "Companies");
(3) Do and perform any and all acts for and on behalf of such Reporting Person
that may be necessary or desirable to complete and execute any such Reports,
complete and execute any amendment or amendments thereto, and timely file such
forms and schedules with the SEC and any stock exchange or similar authority;
and
(4) Take any other action of any type whatsoever in connection with the
foregoing which, in the opinion of the Attorney-in-Fact, may be of benefit to,
in the best interest of, or legally required by, such Reporting Person, it being
understood that the documents executed by the Attorney-in-Fact on behalf of such
Reporting Person, pursuant to this Power of Attorney, shall be in such form and
shall contain such terms and conditions as the Attorney-in-Fact may approve in
his discretion.
Each Reporting Person hereby grants to the Attorney-in-Fact full power and
authority to do and perform all 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 personally present, with full power of substitution or
revocation, hereby ratifying and confirming all that the Attorney-in-Fact, or
his 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. Each
Reporting Person acknowledges that the Attorney-in-Fact, in serving in such
capacity at the request of the Reporting Persons, is not hereby assuming, nor is
the Company hereby assuming, any of such Reporting Person's responsibilities to
comply with Section 16 or Section 13 of the Exchange Act.
This Power of Attorney shall remain in full force and effect with respect to
each Reporting Person until such Reporting Person is no longer required to file
Forms 3, 4 and 5 or Schedules 13G/D with respect to such Reporting Person's
holdings of and transactions in securities issued by the Company, unless earlier
revoked by such Reporting Person in a signed writing delivered to the
Attorney-in-Fact. Each Reporting Person acknowledges that the Attorney-in-Fact,
in serving in such capacity at the request of the Reporting Persons, is not
hereby assuming any of the Reporting Persons' responsibilities to comply with
state or federal securities laws.
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be
executed as of this 26th day of February, 2009.
/s/ Douglas A. Roeder, an individual