Annual Statement of Changes in Beneficial Ownership (5)
March 15 2019 - 1:18PM
Edgar (US Regulatory)
FORM 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).
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Form 3 Holdings Reported
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X
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Form 4 Transactions Reported
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0362
Estimated average burden
hours per response...
1.0
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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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Salem Enrique T
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2. Issuer Name
and
Ticker or Trading Symbol
DOCUSIGN INC [DOCU]
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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 BAIN CAPITAL VENTURE INVESTORS, LLC, 200 CLARENDON STREET
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3. Statement for Issuer's Fiscal Year Ended
(MM/DD/YYYY)
1/31/2019
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(Street)
BOSTON, MA 02116
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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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)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. 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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Amount
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(A) or (D)
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Price
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Common Stock
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10/23/2018
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J4
(1)
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274
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A
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$0.00
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61115
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D
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Common Stock
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12/18/2018
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J4
(1)
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548
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A
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$0.00
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61703
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D
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Common Stock
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4817645
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I
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See Footnote
(2)
(3)
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Common Stock
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89811
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I
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See Footnote
(4)
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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 Derivate Security
(Instr. 3)
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2. Conversion or Exercise Price of Derivative Security
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3. Trans. Date
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3A. Deemed Execution Date, if any
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4. Trans. 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
(MM/DD/YYYY)
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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 at End of Issuer's Fiscal Year
(Instr. 4)
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10. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
(Instr. 4)
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11. Nature of Indirect Beneficial Ownership
(Instr. 4)
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(A)
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(D)
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Date Exercisable
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Expiration Date
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Title
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Amount or Number of Shares
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Explanation of Responses:
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(1)
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Represents shares received in a pro rata distribution from KPCB Digital Growth Fund, LLC to its members without additional consideration.
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(2)
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Represents shares of Common Stock held directly by BCIP Venture Associates ("BCIP Venture") BCIP Venture Associates-B ("BCIP Venture-B"), BCIP Venture Associates II, LP ("BCIP Venture II"), BCIP Venture Associates II-B, LP ("BCIP Venture II-B"), Bain Capital Venture Fund 2012, L.P. ("Venture 2012"), Bain Capital Venture Fund 2014, L.P. ("Venture 2014") and Bain Capital Venture Coinvestment Fund, L.P. ("Coinvestment" and, collectively, the "Bain Venture Entities").
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(3)
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Bain Capital Venture Investors, LLC ("BCVI")is the ultimate general partner of each of Venture 2012, Venture 2014 and Coinvestment and governs the investment strategy and decision making process with respect to investments held by each of BCIP Venture, BCIP Venture-B, BCIP Venture II and BCIP Venture II-B. Mr. Salem is a member of the Executive Committee and a Managing Director of BCVI. By virtue of the relationships described in this footnote, Mr. Salem may be deemed to share voting and dispositive power with respect to all of the shares of Common Stock held by the Bain Venture Entities. Mr. Salem disclaims beneficial ownership except to the extent of his pecuniary interest therein.
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(4)
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Represents shares of Common Stock held directly by NPI Capital, LLC. Mr. Salem is the managing member of NPI Capital, LLC.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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Salem Enrique T
C/O BAIN CAPITAL VENTURE INVESTORS, LLC
200 CLARENDON STREET
BOSTON, MA 02116
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X
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Signatures
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/s/ Enrique Salem
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3/15/2019
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 4(b)(v).
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**
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Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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Note:
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File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure.
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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.
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