FORM 3 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES 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*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 09/28/2016 |
3. Issuer Name and Ticker or Trading Symbol
Tabula Rasa HealthCare, Inc. [ TRHC ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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5. If Amendment, Date of Original Filed
(Month/Day/Year) |
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6. Individual or Joint/Group Filing (Check Applicable Line)
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Table I - Non-Derivative Securities Beneficially Owned | |||
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1. Title of Security (Instr. 4) | 2. Amount of Securities Beneficially Owned (Instr. 4) | 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 4. Nature of Indirect Beneficial Ownership (Instr. 5) |
Common Stock | 83,160 | D |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
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1. Title of Derivative Security (Instr. 4) | 2. Date Exercisable and Expiration Date (Month/Day/Year) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 6. Nature of Indirect Beneficial Ownership (Instr. 5) | ||
Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Series A Preferred Stock | (1) | (1) | Common Stock | 1,043,510 | (2) | D(3) | |
Series A-1 Preferred Stock | (1) | (1) | Common Stock | 668,353 | (2) | D(3) | |
Series B Preferred Stock | (1) | (1) | Common Stock | 119,055 | (2) | D(3) |
1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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Explanation of Responses: |
1. All series of Preferred Stock will automatically convert into Tabula Rasa HealthCare, Inc. (the "Issuer") common stock immediately prior to the closing of the initial public offering and have no expiration date. |
2. This report is filed jointly by Originate Growth Fund #1Q, L.P. ("Originate #1Q"), Originate Growth GP, LLC ("Originate GP"), Glen Bressner ("Bressner"), Eric Arnson ("Arnson"), and Michael Gausling ("Gausling"). Originate #1Q is the record holder of 2,024,410 shares of Series A Preferred Stock, which will automatically convert into 1,043,510 shares of common stock upon the closing of the Issuer's initial public offering. Originate #1Q is the record holder of 1,296,605 shares of Series A-1 Preferred Stock, which will automatically convert into 668,353 shares of common stock upon the closing of the Issuer's initial public offering. Originate #1Q is the record holder of 230,968 shares of Series B Preferred Stock, which will automatically convert into 119,055 shares of common stock upon the closing of the Issuer's initial public offering. |
3. The shares are held by Originate #1Q. The general partner of Originate #1Q is Originate GP, a limited liability company. The members of Originate GP are Bressner, Arnson, and Gausling. The members of Originate #1Q share voting and dispositive power over the shares held by Originate #1Q. Each of these individuals disclaims beneficial ownership of such shares, except to the extent of his pecuniary interest. |
Remarks: |
Originate Growth Fund #1Q, L.P. By: Originate Growth GP, LLC By: /s/ Glen Bressner, Managing Partner | 09/28/2016 | |
Originate Growth GP, LLC By: /s/ Glen Bressner, Managing Partner | 09/28/2016 | |
/s/ Glen Bressner | 09/28/2016 | |
/s/ Eric Arnson | 09/28/2016 | |
/s/ Michael J. Gausling | 09/28/2016 | |
** 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 5 (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. |