1. Name and Address of Reporting Person * |
Â
Efstratis E. Nicholaus |
|
2. Date of Event Requiring Statement (Month/Day/Year) 11/12/2015 |
3. Issuer Name and Ticker or Trading Symbol INSTRUCTURE INC [INST]
|
C/O INSTRUCTURE, INC., 6330 SOUTH 3000 EAST, SUITE 700 |
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
__X__ Director |
__X__ 10% Owner |
_____ Officer (give title below) |
_____ Other (specify below) |
|
|
5. If Amendment, Date Original Filed(Month/Day/Year)
|
SALT LAKE CITY, UT 84121 |
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 Beneficially Owned |
|
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
|
39,149
|
I
|
By NKE Investments, LLC
(1)
|
Common Stock
|
253,500
|
I
|
By Epic Expansion Capital Annex, LLC
(2)
|
Common Stock
|
94,612
|
I
|
By Epic Venture Fund IV, LLC
(2)
|
Common Stock
|
35,911
|
I
|
By Zions SBIC LLC
(2)
|
|
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 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 |
Series A Preferred Stock
|
Â
(3)
|
Â
(4)
|
Common Stock
|
319,306
|
$
(3)
|
I
|
By Epic Expansion Capital Annex, LLC
(2)
|
Series A Preferred Stock
|
Â
(3)
|
Â
(4)
|
Common Stock
|
1,352,194
|
$
(3)
|
I
|
By Epic Venture Fund IV, LLC
(2)
|
Series A Preferred Stock
|
Â
(3)
|
Â
(4)
|
Common Stock
|
26,623
|
$
(3)
|
I
|
By Zions SBIC LLC
(2)
|
Series B Preferred Stock
|
Â
(5)
|
Â
(4)
|
Common Stock
|
784,314
|
$
(5)
|
I
|
By Epic Venture Fund IV, LLC
(2)
|
Series B Preferred Stock
|
Â
(5)
|
Â
(4)
|
Common Stock
|
784,313
|
$
(5)
|
I
|
By Zions SBIC LLC
(2)
|
Series C Preferred Stock
|
Â
(6)
|
Â
(4)
|
Common Stock
|
378,799
|
$
(6)
|
I
|
By Epic Venture Fund IV, LLC
(2)
|
Series C Preferred Stock
|
Â
(6)
|
Â
(4)
|
Common Stock
|
143,777
|
$
(6)
|
I
|
By Zions SBIC LLC
(2)
|
Series D Preferred Stock
|
Â
(7)
|
Â
(4)
|
Common Stock
|
62,892
|
$
(7)
|
I
|
By Epic Venture Fund IV, LLC
(2)
|
Series D Preferred Stock
|
Â
(7)
|
Â
(4)
|
Common Stock
|
213,836
|
$
(7)
|
I
|
By Zions SBIC LLC
(2)
|
Series E Preferred Stock
|
Â
(8)
|
Â
(4)
|
Common Stock
|
273,710
|
$
(8)
|
I
|
By Epic Expansion Capital, LLC
(2)
|
* |
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). |
(1) |
Mr. Efstratis has voting and dispositive power over the shares held by NKE Investments, LLC. |
(2) |
Mr. Efstratis has shared voting and investment power with respect to the shares held by Epic Expansion Capital Annex, LLC, Epic Expansion Capital, LLC, Epic Venture Fund IV, LLC and Zions SBIC LLC. Mr. Efstratis disclaims beneficial ownership of the securities held by such entities, except to the extent of any pecuniary interest therein. |
(3) |
The Series A Preferred Stock is convertible into Common Stock of the Issuer at the option of the holder. The Series A Preferred Stock will automatically convert into Common Stock of the Issuer on a 1-to-1 basis upon closing of the initial public offering of the Issuer. |
(4) |
Not applicable. |
(5) |
The Series B Preferred Stock is convertible into Common Stock of the Issuer at the option of the holder. The Series B Preferred Stock will automatically convert into Common Stock of the Issuer on a 1-to-1 basis upon closing of the initial public offering of the Issuer. |
(6) |
The Series C Preferred Stock is convertible into Common Stock of the Issuer at the option of the holder. The Series C Preferred Stock will automatically convert into Common Stock of the Issuer on a 1-to-1 basis upon closing of the initial public offering of the Issuer. |
(7) |
The Series D Preferred Stock is convertible into Common Stock of the Issuer at the option of the holder. The Series D Preferred Stock will automatically convert into Common Stock of the Issuer on a 1-to-1 basis upon closing of the initial public offering of the Issuer. |
(8) |
The Series E Preferred Stock is convertible into Common Stock of the Issuer at the option of the holder. The Series E Preferred Stock will automatically convert into Common Stock of the Issuer upon the closing of the initial public offering at a ratio depending upon the Issuer's initial public offering price. |