SEC FORM
3
SEC Form 3
| FORM 3 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF 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
|
| 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*
| C/O HUMMER WINBLAD EQUITY PARTNERS V, |
| LLC, PIER 33 SOUTH, THE EMBARCADERO |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
04/03/2014
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3. Issuer Name and Ticker or Trading Symbol
Five9, Inc.
[ FIVN ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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Director |
X |
10% Owner |
|
Officer (give title below) |
|
Other (specify below) |
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5. If Amendment, Date of Original Filed
(Month/Day/Year)
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6. Individual or Joint/Group Filing (Check Applicable Line)
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Form filed by One Reporting Person |
| X |
Form filed by More than One Reporting Person |
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| Table I - Non-Derivative Securities Beneficially Owned |
|---|
| 1. Title of Security (Instr.
4)
|
2.
Amount of Securities Beneficially Owned (Instr.
4)
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3. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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4. Nature of Indirect Beneficial Ownership (Instr.
5)
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| Common Stock |
8,410,041 |
D
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Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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|---|
| 1. Title of Derivative Security (Instr.
4)
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2. Date Exercisable and Expiration Date
(Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr.
4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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6. Nature of Indirect Beneficial Ownership (Instr.
5)
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| Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
1. Name and Address of Reporting Person*
| C/O HUMMER WINBLAD EQUITY PARTNERS V, |
| LLC, PIER 33 SOUTH, THE EMBARCADERO |
(Street)
|
1. Name and Address of Reporting Person*
| PIER 33 SOUTH, THE EMBARCADERO |
|
(Street)
|
1. Name and Address of Reporting Person*
| PIER 33 SOUTH, THE EMBARCADERO |
|
(Street)
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1. Name and Address of Reporting Person*
| PIER 33 SOUTH, THE EMBARCADERO |
|
(Street)
|
1. Name and Address of Reporting Person*
| PIER 33 SOUTH, THE EMBARCADERO |
|
(Street)
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| Explanation of Responses: |
|
| Remarks: |
|
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/s/ Ingrid Chiavacci, attorney-in-fact for Hummer Winblad Venture Partners V, L.P. |
04/03/2014 |
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/s/ Ingrid Chiavacci, attorney-in-fact for Hummer Winblad Equity Partners V, L.L.C. |
04/03/2014 |
|
/s/ Ingrid Chiavacci, attorney-in-fact for Hummer Winblad Venture Partners V-A, L.P. |
04/03/2014 |
|
/s/ Ingrid Chiavacci, attorney-in-fact for John Hummer |
04/03/2014 |
|
/s/ Ingrid Chiavacci, attorney-in-fact for Ann Winblad |
04/03/2014 |
|
** 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 Number. |
Exhibit 24
POWER OF ATTORNEY
Each of the undersigned entities and individuals (collectively, the
"Reporting Persons") hereby authorizes and designates Hummer Winblad Equity
Partners V, L.L.C. or such other person or entity as is designated in writing by
Ingrid Chiavacci (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 Ingrid
Chiavacci (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.
March 27, 2014 Hummer Winblad Equity Partners V, L.L.C.,
a Delaware Limited Liability Company
By: /s/ John Hummer
-------------------------
John Hummer,
Managing Member
March 27, 2014 Hummer Winblad Venture Partners V, L.P.,
a Delaware Limited Partnership
By: Hummer Winblad Equity Partners V, L.L.C.,
a Delaware Limited Liability Company
Its General Partner
By: /s/ John Hummer
-------------------------
John Hummer,
Managing Member
March 27, 2014 Hummer Winblad Venture Partners V-A, L.P.,
a Delaware Limited Partnership
By: Hummer Winblad Equity Partners V, L.L.C.,
a Delaware Limited Liability Company
Its General Partner
By: /s/ John Hummer
-------------------------
John Hummer,
Managing Member
March 27, 2014 By: /s/ John Hummer
-------------------------
John Hummer
March 27, 2014 By: /s/ Ann Winblad
-------------------------
Ann Winblad
March 27, 2014 By: /s/ Mitchell Kertzman
-------------------------
Mitchell Kertzman
