FORM 3
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Washington, D.C. 20549 |
OMB APPROVAL
OMB Number: 3235-0104 Estimated average burden hours per response... 0.5 |
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1. Name and Address of Reporting Person
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2. Date of Event Requiring Statement (MM/DD/YYYY)
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3. Issuer Name and Ticker or Trading Symbol Facebook Inc [FB] |
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4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director
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X
___ 10% Owner
_____ Officer (give title below) _____ Other (specify below) |
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5. If Amendment, Date Original Filed
(MM/DD/YYYY)
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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) |
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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) |
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Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Series C Convertible Preferred Stock (1) | (1) | (1) | Class B Common Stock (2) | 34367483 | (1) | I | See footnote (3) |
Series C Convertible Preferred Stock (1) | (1) | (1) | Class B Common Stock (2) | 626420 | (1) | I | See footnote (4) |
Class B Common Stock (2) | (2) | (2) | Class A Common Stock | 5265340 | (2) | I | See footnote (3) |
Class B Common Stock (2) | (2) | (2) | Class A Common Stock | 95980 | (2) | I | See footnote (4) |
Reporting Owners
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Reporting Owner Name / Address |
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Director | 10% Owner | Officer | Other | ||
Meritech Management Associates III L.L.C.
245 LYTTON AVENUE, SUITE 350 PALO ALTO, CA 94301 |
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X |
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Meritech Capital Associates III L.L.C.
245 LYTTON AVENUE, SUITE 350 PALO ALTO, CA 94301 |
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X |
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Meritech Capital Partners III LP
245 LYTTON AVENUE, SUITE 350 PALO ALTO, CA 94301 |
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X |
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MERITECH CAPITAL AFFILIATES III L P
245 LYTTON AVENUE, SUITE 350 PALO ALTO, CA 94301 |
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X |
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MADERA PAUL S
245 LYTTON AVENUE, SUITE 350 PALO ALTO, CA 94301 |
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X |
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GORDON MICHAEL B
245 LYTTON AVENUE, SUITE 350 PALO ALTO, CA 94301 |
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X |
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Ward Rob
245 LYTTON AVENUE, SUITE 350 PALO ALTO, CA 94301 |
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X |
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Bischof George
245 LYTTON AVENUE, SUITE 350 PALO ALTO, CA 94301 |
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X |
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Signatures
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/s/ Joel Backman as attorney-in-fact for Paul S. Madera, as a managing member of Meritech Management Associates III L.L.C. | 5/17/2012 | |
** Signature of Reporting Person | Date | |
/s/ Joel Backman as attorney-in-fact for Paul S. Madera, as a managing member of Meritech Management Associates III L.L.C., a managing member of Meritech Capital Associates III L.L.C. | 5/17/2012 | |
** Signature of Reporting Person | Date | |
/s/ Joel Backman as attorney-in-fact for Paul S. Madera, as a managing member of Meritech Management Associates III L.L.C., a managing member of Meritech Capital Associates III L.L.C., the general partner of Meritech Capital Partners III L.P. | 5/17/2012 | |
** Signature of Reporting Person | Date | |
/s/ Joel Backman as attorney-in-fact for Paul S. Madera, as a managing member of Meritech Management Associates III L.L.C., a managing member of Meritech Capital Associates III L.L.C., the general partner of Meritech Capital Affiliates III L.P. | 5/17/2012 | |
** Signature of Reporting Person | Date | |
/s/ Joel Backman as attorney-in-fact for Paul S. Madera | 5/17/2012 | |
** Signature of Reporting Person | Date | |
/s/ Joel Backman as attorney-in-fact for Michael B. Gordon | 5/17/2012 | |
** Signature of Reporting Person | Date | |
/s/ Joel Backman as attorney-in-fact for Rob Ward | 5/17/2012 | |
** Signature of Reporting Person | Date | |
/s/ Joel Backman as attorney-in-fact for George Bischof | 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. |
EXHIBIT 24 AGREEMENT TO FILE JOINTLY AND STATEMENT APPOINTING DESIGNATED FILER AND AUTHORIZED SIGNATORY Each of the undersigned entities and individuals (collectively, the "Reporting Persons") hereby authorizes and designates Meritech Management Associates III L.L.C. or such other person or entity as is designated in writing by Paul Madera (the "Designated Filer") as the beneficial owner to prepare and file on behalf of such Reporting Person individually, or jointly together with the other Reporting Persons, any and all reports, notices, communications and other documents (including, but not limited to, reports on Schedule 13D, Schedule 13G, Form 13-F, Form 3, Form 4 and Form 5) that such Reporting Person may be required to file with the United States Securities and Exchange Commission pursuant to the Securities Act of 1933, as amended (together with the implementing regulations thereto, the "Act") and the Securities Exchange Act of 1934, as amended (together with the implementing regulations thereto, the "Exchange Act") (collectively, the "Reports") with respect to each Reporting Person's ownership of, or transactions in, securities of any entity whose securities are beneficially owned (directly or indirectly) by such Reporting Person (collectively, the "Companies"). Each Reporting Person hereby further authorizes and designates Joel Backman (the "Authorized Signatory") to execute and file on behalf of such Reporting Person the Reports and to perform any and all other acts, which in the opinion of the Designated Filer or Authorized Signatory may be necessary or incidental to the performance of the foregoing powers herein granted. The authority of the Designated Filer and the Authorized Signatory under this Document with respect to each Reporting Person shall continue until such Reporting Person is no longer required to file any Reports with respect to the Reporting Person's ownership of, or transactions in, the securities of the Companies, unless earlier revoked in writing. Each Reporting Person acknowledges that the Designated Filer and the Authorized Signatory are not assuming any of the Reporting Person's responsibilities to comply with the Act or the Exchange Act. December 5, 2011 MERITECH MANAGEMENT ASSOCIATES III L.L.C., a Delaware Limited Liability Company By: /s/ Paul Madera Paul Madera, Managing Member December 5, 2011 MERITECH CAPITAL ASSOCIATES III L.L.C., a Delaware Limited Liability CompanyBy: MERITECH MANAGEMENT ASSOCIATES III L.L.C., a Delaware Limited Liability Company Its General Partner By: /s/ Paul Madera Paul Madera, Managing Member December 5, 2011 MERITECH CAPITAL PARTNERS III L.P., a Delaware Limited Partnership By: MERITECH CAPITAL ASSOCIATES III L.L.C., a Delaware Limited Liability Company Its General Partner By: MERITECH MANAGEMENT ASSOCIATES III L.L.C., a Delaware Limited Liability Company Its General Partner By: /s/ Paul Madera Paul Madera, Managing Member December 5, 2011 MERITECH CAPITAL AFFILIATES III L.P., a Delaware Limited Partnership By: MERITECH CAPITAL ASSOCIATES III L.L.C., a Delaware Limited Liability Company Its General Partner By: MERITECH MANAGEMENT ASSOCIATES III L.L.C., a Delaware Limited Liability Company Its General Partner By: /s/ Paul Madera Paul Madera, Managing Member December 5, 2011 By: /s/ Paul Madera Paul Madera December 5, 2011 By: /s/ Mike Gordon Mike Gordon December 5, 2011 By: /s/ George Bischof George Bischof December 5, 2011 By: /s/ Rob Ward Rob Ward