Annual Statement of Changes in Beneficial Ownership (5)
15 2월 2020 - 7:59AM
Edgar (US Regulatory)
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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).
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Form 3 Holdings Reported
[X]
Form 4 Transactions Reported
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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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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1. Name and Address of Reporting Person
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RICCI PAUL | 2. Issuer Name and Ticker or Trading SymbolPersonalis, Inc. [PSNL] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__X__ Director _____ 10% Owner _____ Officer (give title below) _____ Other (specify below)
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(Last)
(First)
(Middle)
C/O PERSONALIS, INC., 1330 O'BRIEN DRIVE | 3. Statement for Issuer's Fiscal Year Ended (MM/DD/YYYY) 12/31/2019 |
(Street)
MENLO PARK, CA 94025
(City)
(State)
(Zip)
| 4. If Amendment, Date Original Filed(MM/DD/YYYY) | 6. Individual or Joint/Group Filing(Check Applicable Line)
_X_ Form Filed by One Reporting Person
___ Form Filed by More than One Reporting Person
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security (Instr. 3) | 2. Trans. Date | 2A. Deemed Execution Date, if any | 3. Trans. Code (Instr. 8) | 4. Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) | 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) | 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 7. Nature of Indirect Beneficial Ownership (Instr. 4) |
Amount | (A) or (D) | Price |
Common Stock | 12/13/2019 | | S4 | 1 | D | $9.81 | 19999 | I | See Footnote (1) |
Common Stock | | | | | | | 20000 | I | See Footnote (2) |
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 Derivate Security (Instr. 3) | 2. Conversion or Exercise Price of Derivative Security | 3. Trans. Date | 3A. Deemed Execution Date, if any | 4. Trans. 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 (MM/DD/YYYY) | 7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4) | 8. Price of Derivative Security (Instr. 5) | 9. Number of Derivative Securities Beneficially Owned at End of Issuer's Fiscal Year (Instr. 4) | 10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) | 11. Nature of Indirect Beneficial Ownership (Instr. 4) |
(A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Explanation of Responses: |
(1) | The shares are held of record by Michael T. Cody, as Trustee of the Paul A. Ricci Irrevocable Trust Under Agreement Dated May 27, 2011, of which the Reporting Person's children are beneficiaries. |
(2) | The shares are held of record by Paul A. Ricci Living Trust Under Agreement Dated June 26, 2006, for which the Reporting Person serves as trustee. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
RICCI PAUL C/O PERSONALIS, INC. 1330 O'BRIEN DRIVE MENLO PARK, CA 94025 | X |
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Signatures
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/s/ Aaron Tachibana, Attorney-in-Fact | | 2/14/2020 |
**Signature of Reporting Person | Date |
Personalis (NASDAQ:PSNL)
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Personalis (NASDAQ:PSNL)
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