FORM 3
|
Washington, D.C. 20549 |
OMB APPROVAL
OMB Number: 3235-0104 Estimated average burden hours per response... 0.5 |
|
|
|
1. Name and Address of Reporting Person
*
|
2. Date of Event Requiring Statement (MM/DD/YYYY)
|
3. Issuer Name and Ticker or Trading Symbol Facebook Inc [FB] |
|
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director
___
X
___ 10% Owner
_____ Officer (give title below) _____ Other (specify below) |
|
|
5. If Amendment, Date Original Filed
(MM/DD/YYYY)
|
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 II - Derivative Securities Beneficially Owned ( e.g. , puts, calls, warrants, options, convertible securities) |
|||||||
1. Title of Derivate Security
(Instr. 4) |
2. Date Exercisable and Expiration Date
(MM/DD/YYYY) |
3. Title and Amount of Securities Underlying Derivative Security
(Instr. 4) |
4. Conversion or Exercise Price of Derivative Security |
5. Ownership Form of Derivative Security: 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 | ||||
Class B Common Stock (1) | (1) | (1) | Class A Common Stock | 139144 | $0.00 | I | By James W. Breyer as Trustee of James W. Breyer 2005 Trust dated March 25, 2005 (2) |
Series B Convertible Preferred Stock (3) | (3) | (3) | Class B Common Stock (1) | 10211171 | $0.00 | I | By James W. Breyer as Trustee of James W. Breyer 2005 Trust dated March 25, 2005 (2) |
Series C Convertible Preferred Stock (4) | (4) | (4) | Class B Common Stock (1) | 633093 | $0.00 | I | By James W. Breyer as Trustee of James W. Breyer 2005 Trust dated March 25, 2005 (2) |
Class B Common Stock (1) | (1) | (1) | Class A Common Stock | 15461 | $0.00 | I | By James W. Breyer as Trustee of James W. Breyer 2011 Annuity Trust 1, dated March 10, 2011 (5) |
Series B Convertible Preferred Stock (3) | (3) | (3) | Class B Common Stock (1) | 633920 | $0.00 | I | By James W. Breyer as Trustee of James W. Breyer 2011 Annuity Trust 1, dated March 10, 2011 (5) |
Series C Convertible Preferred Stock (4) | (4) | (4) | Class B Common Stock (1) | 70343 | $0.00 | I | By James W. Breyer as Trustee of James W. Breyer 2011 Annuity Trust 1, dated March 10, 2011 (5) |
Series B Convertible Preferred Stock (3) | (3) | (3) | Class B Common Stock (1) | 140419959 | $0.00 | I | By Accel IX L.P. (6) |
Series C Convertible Preferred Stock (4) | (4) | (4) | Class B Common Stock (1) | 9107771 | $0.00 | I | By Accel IX L.P. (6) |
Series B Convertible Preferred Stock (3) | (3) | (3) | Class B Common Stock (1) | 14961394 | $0.00 | I | By Accel IX Strategic Partners L.P. (7) |
Series C Convertible Preferred Stock (4) | (4) | (4) | Class B Common Stock (1) | 970259 | $0.00 | I | By Accel IX Strategic Partners L.P. (7) |
Series B Convertible Preferred Stock (3) | (3) | (3) | Class B Common Stock (1) | 13090187 | $0.00 | I | By Accel Investors 2005 L.L.C. (8) |
Series C Convertible Preferred Stock (4) | (4) | (4) | Class B Common Stock (1) | 849027 | $0.00 | I | By Accel Investors 2005 L.L.C. (8) |
Class B Common Stock (1) | (1) | (1) | Class A Common Stock | 9949820 | $0.00 | I | By Accel Growth Fund L.P. (9) |
Class B Common Stock (1) | (1) | (1) | Class A Common Stock | 194230 | $0.00 | I | By Accel Growth Fund Strategic Partners L.P. (10) |
Class B Common Stock (1) | (1) | (1) | Class A Common Stock | 132570 | $0.00 | I | By Accel Growth Fund Investors 2009 L.L.C. (11) |
Remarks:
This report is the same as the Form 3 filed by Accel IX L.P. of identical date and together comprise a single Form 3. Combined the reports report the holdings for the following reporting persons: Accel Growth Fund Investors 2009 L.L.C., Accel Growth Fund Associates L.L.C., Accel Growth Fund L.P., Accel Growth Fund Strategic Partners L.P., Accel IX Associates L.L.C., Accel IX L.P., Accel IX Strategic Partners L.P., Accel Investors 2005 L.L.C., James W. Breyer, Trustee of James W. Breyer 2005 Trust dated March 25, 2005, James W. Breyer, Trustee of James W. Breyer 2011 Annuity Trust 1, dated March 10, 2011, James W. Breyer, Ping Li, Kevin J. Efrusy, Theresia Gouw Ranzetta and Arthur C. Patterson. |
Reporting Owners
|
|||||
Reporting Owner Name / Address |
|
||||
Director | 10% Owner | Officer | Other | ||
ACCEL IX LP
C/O ACCEL PARTNERS 428 UNIVERSITY AVENUE PALO ALTO, CA 94301 |
|
X |
|
|
|
GOUW RANZETTA THERESIA
C/O ACCEL PARTNERS 428 UNIVERSITY AVENUE PALO ALTO, CA 94301 |
|
X |
|
|
|
EFRUSY KEVIN
C/O ACCEL PARTNERS 428 UNIVERSITY AVENUE PALO ALTO, CA 94301 |
|
X |
|
|
|
PATTERSON ARTHUR C
C/O ACCEL PARTNERS 428 UNIVERSITY AVENUE PALO ALTO, CA 94301 |
|
X |
|
|
|
James W. Breyer, Trustee of The James W. Breyer 2005 Trust, dated March 25, 2005
C/O ACCEL PARTNERS 428 UNIVERSITY AVENUE PALO ALTO, CA 94301 |
|
X |
|
|
|
James W. Breyer, Trustee of The James W. Breyer 2011 Annuity Trust 1, dated March 10, 2011
C/O ACCEL PARTNERS 428 UNIVERSITY AVENUE PALO ALTO, CA 94301 |
|
X |
|
|
Signatures
|
||
/s/ Tracy L. Sedlock as attorney-in-fact James W. Breyer, as a managing member of Accel IX Associates L.L.C., the General Partner of Accel IX L.P. | 5/17/2012 | |
** Signature of Reporting Person | Date | |
Tracy L. Sedlock as attorney-in-fact for Theresia Gouw Ranzetta | 5/17/2012 | |
** Signature of Reporting Person | Date | |
Tracy L. Sedlock as attorney-in-fact for Kevin Efrusy | 5/17/2012 | |
** Signature of Reporting Person | Date | |
Tracy L. Sedlock as attorney-in-fact for Arthur C. Patterson | 5/17/2012 | |
** Signature of Reporting Person | Date | |
Tracy L. Sedlock as attorney-in-fact for James W. Breyer as Trustee of James W. Breyer 2005 Trust dated March 25, 2005 | 5/17/2012 | |
** Signature of Reporting Person | Date | |
Tracy L. Sedlock as attorney-in-fact for James W. Breyer as Trustee of James W. Breyer 2011 Annuity Trust 1, dated March 10, 2011 | 5/17/2012 | |
** 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 control number. |
LIMITED POWER OF ATTORNEY
The undersigned hereby constitutes and appoints Theodore W. Ullyot,
David Kling, Michael Johnson and Tracy Sedlock, or any of them, the undersigned's true and lawful attorney-in-fact to:
(1) execute for and on behalf of the undersigned, in the undersigned's capacity as an officer, director and/or stockholder of any corporation or other person in which an investment fund affiliated with Accel Management Co. L.L.C makes an investment (each, a "Company"), Forms 3, 4s and 5s and amendments thereto in accordance with Section 16(a) of the Exchange Act, and the rules and regulations thereunder;
(2) do and perform any and all acts for and on behalf of the undersigned that may be necessary or desirable to complete and execute any such Forms 3, 4s and 5s and timely file such form with the Securities and Exchange Commission and any stock exchange or similar authority; and
(3) take any other action of any type whatsoever in connection with the foregoing which, in the opinion of such attorney-in-fact, may be of benefit to, in the best interest of, or legally required by, the undersigned, it being understood that the documents executed by such attorney-in-fact on behalf of the undersigned pursuant to this Power of Attorney shall be in such form and shall contain such terms and conditions as such attorney-in-fact may approve in such attorney-in-fact's discretion.
The undersigned hereby grants to each such attorney-in-fact full power and authority to do and perform each and every act and thing whatsoever requisite, necessary or proper to be done in the exercise of any of the rights and powers herein granted, as fully to all intents and purposes as the undersigned might or could do if personally present, with full power of substitution and revocation, hereby ratifying and confirming all that each such attorney-in-fact, or each such attorney-in-fact's substitute or substitutes, shall lawfully do or cause to be done by virtue of this power of attorney and the rights and powers herein granted. The undersigned acknowledges that each of the foregoing attorneys-in-fact, in serving in such capacity at the request of the undersigned, are not assuming, nor is the Company assuming, any of the undersigned's responsibilities to comply with Section 16 of the Exchange Act.
The undersigned agrees that each such attorney-in-fact may rely entirely on information furnished orally or in writing by the undersigned to each such attorney-in-fact. The undersigned also agrees to indemnify and hold harmless the Company and each such attorney-in-fact against any losses, claims, damages or liabilities (or actions in these respects) that arise out of or are based on any untrue statement or omission of necessary facts in the information provided by the undersigned to such attorney-in-fact for purposes of executing, acknowledging, delivering and filing Forms 3, 4s or 5s (including amendments thereto) and agrees to reimburse the Company and each such attorney-in-fact for any legal or other expenses reasonably incurred in connection with investigating or defending against any such loss, claim, damage, liability or action.
This Power of Attorney shall remain in full force and effect until the undersigned is no longer required to file Forms 3, 4s and 5s with respect to the undersigned's holdings of and transactions in securities issued by the Company, unless earlier revoked by the undersigned in a signed writing delivered to the foregoing attorneys-in-fact.
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be executed as of this 10th day of May, 2012.
/s/ James Breyer James Breyer, as a managing member of each of: Accel IX Associates L.L.C. Accel Investors 2005 L.L.C. Accel Growth Fund Associates L.L.C. Accel Growth Fund Investors 2009 L.L.C And as Trustee of each of the: James W. Breyer 2005 Trust dated March 25, 2005 James W. Breyer 2011 Annuity Trust I dated March 10, 2011 |
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be
executed as of this 10th day of May, 2012.
/s/ Arthur C. Patterson Arthur C. Patterson /s/ Kevin J. Efrusy Kevin J. Efrusy /s/ Theresia Gouw Ranzettta Theresia Gouw Ranzettta /s/ Ping Li Ping Li |