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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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*
Hald Borge

(Last) (First) (Middle)
C/O MEDALLIA, INC.
575 MARKET STREET, SUITE 1850

(Street)
SAN FRANCISCO CA 94105

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
Medallia, Inc. [ MDLA ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director X 10% Owner
Officer (give title below) Other (specify below)
3. Date of Earliest Transaction (Month/Day/Year)
12/09/2019
4. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
Form filed by One Reporting Person
X Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security (Instr. 3) 2. Transaction Date (Month/Day/Year) 2A. Deemed Execution Date, if any (Month/Day/Year) 3. Transaction 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)
Code V Amount (A) or (D) Price
Common Stock 12/09/2019 G 160,000 D $0.00 3,279,255 D
Common Stock 12/09/2019 G 160,000 D $0.00 3,371,282 I See footnote(1)
Common Stock 1,865,289 I See footnote(2)
Common Stock 465,734 I See footnote(3)
Common Stock 1,615,289 I See footnote(4)
Common Stock 465,734 I See footnote(5)
Common Stock 157,973 I See footnote(6)
Common Stock 1,500,000 I See footnote(7)
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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 Securities Underlying Derivative Security (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: Direct (D) or Indirect (I) (Instr. 4) 11. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V (A) (D) Date Exercisable Expiration Date Title Amount or Number of Shares
1. Name and Address of Reporting Person*
Hald Borge

(Last) (First) (Middle)
C/O MEDALLIA, INC.
575 MARKET STREET, SUITE 1850

(Street)
SAN FRANCISCO CA 94105

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
X Director X 10% Owner
Officer (give title below) Other (specify below)
1. Name and Address of Reporting Person*
Pressman Amy E

(Last) (First) (Middle)
C/O MEDALLIA, INC.
575 MARKET STREET, SUITE 1850

(Street)
SAN FRANCISCO CA 94105

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
X Director X 10% Owner
Officer (give title below) Other (specify below)
Explanation of Responses:
1. The shares are held of record by Ms. Pressman. The reporting persons are husband and wife.
2. The shares are held of record by the Borge Hald Irrevocable Trust U/A/D 11/4/2019 First Republic Trust Company of Delaware LLC, Trustee for which Mr. Hald serves as an investment advisor. In prior Forms 3 and 4, these shares were reported as held of record by the Borge Hald 2014 Irrevocable Descendant's Trust for which Mr. Hald serves as trustee.
3. The shares are held of record by the Borge Hald Irrevocable Trust II U/A/D 11/4/2019 First Republic Trust Company of Delaware LLC, Trustee for which Mr. Hald serves as an investment advisor. In prior Forms 3 and 4, these shares were reported as held of record by the Borge Hald 2011 Irrevocable Remainder Trust for which Mr. Hald serves as trustee.
4. The shares are held of record by the Amy Hald Irrevocable Trust U/A/D 11/4/2019 First Republic Trust Company of Delaware LLC, Trustee for which Ms. Pressman serves as an investment advisor. In prior Forms 3 and 4, these shares were reported as held of record by the Amy Hald 2014 Irrevocable Descendant's Trust for which Ms. Pressman serves as trustee.
5. The shares are held of record by the Amy Hald Irrevocable Trust II U/A/D 11/4/2019 First Republic Trust Company of Delaware LLC, Trustee for which Ms. Pressman serves as an investment advisor. In prior Forms 3 and 4, these shares were reported as held of record by the Amy Hald 2011 Irrevocable Remainder Trust for which Ms. Pressman serves as trustee.
6. The shares are held of record by the Amy Hald Irrevocable Trust III U/A/D 11/4/2019 First Republic Trust Company of Delaware LLC, Trustee for which Ms. Pressman serves as an investment advisor. In prior Forms 3 and 4, these shares were reported as held of record by the Amy Hald Irrevocable Remainder Trust for which Ms. Pressman serves as trustee.
7. The shares are held of record by the Hald 2011 Irrevocable Children's Trust dtd 8/4/2011 First Republic Trust Company of Delaware LLC, Trustee for which Mr. Hald and Ms. Pressman serves as an investment advisor. In prior Forms 3 and 4, these shares were reported as held of record by the Hald 2011 Irrevocable Children's Trust for which Mr. Hald and Ms. Pressman serve as co-trustees.
Remarks:
Exhibit 24.1 - Power of Attorney - Borge Hald Exhibit 24.2 - Power of Attorney - Amy E. Pressman
/s/ Vanessa Pon, by power of attorney for Borge Hald 03/13/2020
/s/ Vanessa Pon, by power of attorney for Amy E. Pressman 03/13/2020
** 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).
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