FORM 4
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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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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
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OMB APPROVAL
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1. Name and Address of Reporting Person
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Andreessen Marc L |
2. Issuer Name
and
Ticker or Trading Symbol
Facebook Inc [ FB ] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__ X __ Director _____ 10% Owner _____ Officer (give title below) _____ Other (specify below) |
C/O ANDREESSEN HOROWITZ, 2865 SAND HILL RD., STE. 101 |
3. Date of Earliest Transaction
(MM/DD/YYYY)
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MENLO PARK, CA 94025 |
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 |
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) | |||
Code | V | Amount | (A) or (D) | Price | ||||||
Class A Common Stock | 11/13/2012 | C | 1604776 | A | $0.00 | 1604776 | I | By Andreessen Horowitz Fund I, L.P. as nominee (1) | ||
Class A Common Stock | 11/13/2012 | J (2) | V | 1604776 | D | $0.00 | 0 | I | By Andreessen Horowitz Fund I, L.P. as nominee (1) | |
Class A Common Stock | 11/13/2012 | C | 3571431 | A | $0.00 | 3571431 | I | By Andreessen Horowitz Fund II, L.P. as nominee (3) | ||
Class A Common Stock | 11/13/2012 | C | 3035700 | A | $0.00 | 3035700 | I | By FBAH, L.P. (4) | ||
Class A Common Stock | 11/13/2012 | J (5) | V | 3035700 | D | $0.00 | 0 | I | By FBAH, L.P. (4) | |
Class A Common Stock | 11/13/2012 | J (6) | V | 466125 | A | $0.00 | 466125 | I | By AH Equity Partners I, L.L.C. (7) | |
Class A Common Stock | 11/13/2012 | J (8) | V | 466125 | D | $0.00 | 0 | I | By AH Equity Partners I, L.L.C. (7) | |
Class A Common Stock | 11/13/2012 | J (9) | V | 159675 | A | $0.00 | 159675 | I | By AH Equity Partners II, L.L.C. (10) | |
Class A Common Stock | 11/13/2012 | J (11) | V | 159675 | D | $0.00 | 0 | I | By AH Equity Partners II, L.L.C. (10) | |
Class A Common Stock | 11/13/2012 | J (12) | V | 9509 | A | $0.00 | 9509 | I | By AH Capital Management, L.L.C. (13) | |
Class A Common Stock | 11/13/2012 | J (14) | V | 9509 | D | $0.00 | 0 | I | By AH Capital Management, L.L.C. (13) | |
Class A Common Stock | 11/13/2012 | J (15) | 7755 | A | $0.00 | 13626 | I | By The Andreessen 1996 Charitable Remainder Unitrust (16) | ||
Class A Common Stock | 11/13/2012 | J (17) | V | 295579 | A | $0.00 | 295579 | I | By The Andreessen 1996 Living Trust (18) |
Table II - Derivative Securities 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 |
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 of Derivative Security: 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 | ||||||||
Class B Common Stock (19) | (19) | 11/13/2012 | C | 1604776 | (19) | (19) | Class A Common Stock (20) | 1604776 | $0.00 | 178308 | I | By Andreessen Horowitz Fund I, L.P. as nominee (1) | |||
Class B Common Stock (19) | (19) | 11/13/2012 | C | 3571431 | (19) | (19) | Class A Common Stock (20) | 3571431 | $0.00 | 0 | I | By Andreessen Horowitz Fund II, L.P. as nominee (3) | |||
Class B Common Stock (19) | (19) | 11/13/2012 | C | 3035700 | (19) | (19) | Class A Common Stock (20) | 3035700 | $0.00 | 0 | I | By FBAH, L.P. (4) |
Reporting Owners
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Reporting Owner Name / Address |
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Director | 10% Owner | Officer | Other | ||
Andreessen Marc L
C/O ANDREESSEN HOROWITZ 2865 SAND HILL RD., STE. 101 MENLO PARK, CA 94025 |
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Signatures
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/s/ David Kling as attorney-in-fact for Marc L. Andreessen | 11/14/2012 | |
** Signature of Reporting Person |
Date
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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. |
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