FORM 5
[ ] Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). [ ] Form 3 Holdings Reported
[ ] Form 4 Transactions Reported
UNITED STATES SECURITIES AND EXCHANGE COMMISSION | OMB APPROVAL |
OMB Number: 3235-0362 | |
Washington, D.C. 20549 | Estimated average burden |
hours per response... 1.0 |
ANNUAL STATEMENT OF CHANGES IN 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
1. Name and Address of Reporting Person * | 2. Issuer Name and Ticker or Trading Symbol | 5. Relationship of Reporting Person(s) to Issuer |
(Check all applicable) |
JAEGER WILFRED E | NEVRO CORP [NVRO] | __X__ Director | _____ 10% Owner | |||||||||||||||||||||||||
(Last) | (First) | (Middle) | 3. Statement for Issuer's Fiscal Year Ended | |||||||||||||||||||||||||
_____ Officer (give title below) | _____ Other (specify below) | |||||||||||||||||||||||||||
(MM/DD/YYYY) | 12/31/2019 | |||||||||||||||||||||||||||
C/O NEVRO CORP., 1800 BRIDGE | ||||||||||||||||||||||||||||
PARKWAY | ||||||||||||||||||||||||||||
(Street) | 4. If Amendment, Date Original Filed(MM/DD/YYYY) 6. Individual or Joint/Group Filing(Check Applicable Line) | |||||||||||||||||||||||||||
REDWOOD CITY, CA 94065 | _X_ Form Filed by One Reporting Person | |||||||||||||||||||||||||||
(City) | (State) | (Zip) | ___ Form Filed by More than One Reporting Person | |||||||||||||||||||||||||
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned | ||||||||||||||||||||||||||||
1.Title of Security | 2. Trans. Date | 2A. Deemed | 3. Trans. Code | 4. Securities Acquired (A) | 5. Amount of Securities Beneficially Owned | 6. | 7. Nature of | |||||||||||||||||||||
(Instr. 3) | Execution | (Instr. 8) | or Disposed of (D) | Following Reported Transaction(s) | Ownership | Indirect | ||||||||||||||||||||||
Date, if any | (Instr. 3, 4 and 5) | (Instr. 3 and 4) | Form: | Beneficial | ||||||||||||||||||||||||
Direct (D) | Ownership | |||||||||||||||||||||||||||
or Indirect | (Instr. 4) | |||||||||||||||||||||||||||
(A) or | (I) | |||||||||||||||||||||||||||
Amount | (D) | Price | (Instr. 4) | |||||||||||||||||||||||||
Common Stock | 11/29/2017 | J5 | 7976 | A | $0.00 | 25341 | I | See | ||||||||||||||||||||
footnote (3) | ||||||||||||||||||||||||||||
Common Stock | 11/29/2017 | J5 | 349 | A | $0.00 | 25341 | I | See | ||||||||||||||||||||
footnote (3) | ||||||||||||||||||||||||||||
Common Stock | 5/9/2018 | J5 | 16302 | A | $0.00 | 25341 | I | See | ||||||||||||||||||||
footnote (3) | ||||||||||||||||||||||||||||
Common Stock | 5/9/2018 | J5 | 714 | A | $0.00 | 25341 | I | See | ||||||||||||||||||||
footnote (3) | ||||||||||||||||||||||||||||
Common Stock | 11/29/2017 | J5 | 1021 | A | $0 | 3106 | I | See | ||||||||||||||||||||
footnote (4) | ||||||||||||||||||||||||||||
Common Stock | 5/9/2018 | J5 | 2085 | A | $0 | 3106 | I | See | ||||||||||||||||||||
footnote (4) | ||||||||||||||||||||||||||||
Common Stock | 11/29/2017 | J5 | 1021 | A | $0 | 3106 | I | See | ||||||||||||||||||||
footnote (5) | ||||||||||||||||||||||||||||
Common Stock | 5/9/2018 | J5 | 2085 | A | $0 | 3106 | I | See | ||||||||||||||||||||
footnote (5) | ||||||||||||||||||||||||||||
Common Stock | 8216 (6) | D | ||||||||||||||||||||||||||
Common Stock | 0 | I | See | |||||||||||||||||||||||||
footnote (7) | ||||||||||||||||||||||||||||
Common Stock | 0 | I | See | |||||||||||||||||||||||||
footnote (8) | ||||||||||||||||||||||||||||
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | ||||||||||||||||||||||||||||
1. Title of Derivate | 2. Conversion | 3. Trans. | 3A. Deemed | 4. Trans. | 5. Number of | 6. Date Exercisable and | 7. Title and Amount of | 8. Price of | 9. Number | 10. | 11. Nature | |||||||||||||||||
Security | or Exercise | Date | Execution | Code | Derivative Securities | Expiration Date | Securities Underlying | Derivative | of | Ownership | of Indirect | |||||||||||||||||
(Instr. 3) | Price of | Date, if any | (Instr. 8) | Acquired (A) or | (MM/DD/YYYY) | Derivative Security | Security | Derivative | Form of | Beneficial | ||||||||||||||||||
Derivative | Disposed of (D) | (Instr. 3 and 4) | (Instr. 5) | Securities | Derivative | Ownership | ||||||||||||||||||||||
Security | (Instr. 3, 4 and 5) | Beneficially | Security: | (Instr. 4) | ||||||||||||||||||||||||
Owned at | Direct (D) | |||||||||||||||||||||||||||
Date | Expiration | Amount or Number of | End of | or Indirect | ||||||||||||||||||||||||
Title | Issuer's | (I) | ||||||||||||||||||||||||||
Exercisable | Date | Shares | Fiscal Year | (Instr. 4) | ||||||||||||||||||||||||
(A) | (D) | (Instr. 4) |
Explanation of Responses:
- Pro rata in-kind distribution from Three Arch Management IV, LLC for no consideration.
- Pro rata in-kind distribution from Three Arch Associates IV, LP for no consideration.
- Shares are held by Wilfred E. Jaeger and Judith F. Jaeger, TTEES of the Jaeger Family Trust DTD 4/30/99.
- Shares are held by Nicholas Graham Jaeger 2002 Irrevocable Trust U/D/T 04/23/2002.
- Shares are held by Emma Louise Jaeger 2002 Irrevocable Trust U/D/T 04/23/2002.
- Includes 2,913 RSUs.
- Shares are held by Three Arch Partners IV, L.P. ("TAP IV"). TAP IV distributed pro rata in-kind to its members 244,599 shares on 11/29/17 and 500,109 shares on 5/9/18.
- Shares are held by Three Arch Associates IV, L.P. ("TAA IV"). TAA IV distributed pro rata in-kind to its members 5,401 shares on 11/29/17 and 11,042 shares on 5/9/18.
Reporting Owners
Reporting Owner Name / Address | Relationships | ||
Director | 10% Owner | OfficerOther | |
JAEGER WILFRED E | |||
C/O NEVRO CORP. | X | ||
1800 BRIDGE PARKWAY | |||
REDWOOD CITY, CA 94065 |
Signatures | ||
/s/ Andrew Galligan, as Attorney-in-Fact for Wilfred E. Jaeger | 2/14/2020 | |
**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).
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 control number.
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Nevro Corp. published this content on 14 February 2020 and is solely responsible for the information contained therein. Distributed by Public, unedited and unaltered, on 14 February 2020 23:16:05 UTC