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
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| 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 FIVE9, INC, BISHOP RANCH 8 |
| 4000 EXECUTIVE PARKWAY, SUITE 400 |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
09/10/2015
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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)
| X |
Director |
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10% Owner |
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Officer (give title below) |
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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)
| X |
Form filed by One Reporting Person |
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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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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 |
| Explanation of Responses: |
| Remarks: |
|
| No securities are beneficially owned. |
|
/s/ David Hill, attorney-in-fact |
09/14/2015 |
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** 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. |
LIMITED POWER OF ATTORNEY
FOR SECTION 13 AND SECTION 16 REPORTING
KNOW ALL PERSONS BY THESE PRESENTS, that the undersigned hereby makes,
constitutes and appoints Barry Zwarenstein, David Hill, Timothy R. Curry, Ruben
A. Garcia, Julia R. Weissman and Frances P. Dea, and each of them, as the
undersigned's true and lawful attorney- in-fact (the "Attorney-in-Fact"), with
full power of substitution and resubstitution, each with the power to act alone
for the undersigned and in the undersigned's name, place and stead, in any and
all capacities to:
1. Prepare, execute and submit to the Securities and Exchange Commission
("SEC"),any national securities exchange or securities quotation system and
Five9, Inc. (the "Company") any and all reports (including any amendment
thereto) of the undersigned required or considered advisable under Section 13 or
Section 16 of the Securities Exchange Act of 1934 (the "Exchange Act") and the
rules and regulations thereunder, with respect to the equity securities of the
Company, including Forms 3, 4 and 5 and Schedule 13D or 13G; and
2. Obtain, as the undersigned's representative and on the undersigned's
behalf, information regarding transactions in the Company's equity securities
from any third party, including the Company and any brokers, dealers, employee
benefit plan administrators and trustees, and the undersigned hereby authorizes
any such third party to release any such information to the Attorney-in-Fact.
The undersigned acknowledges that:
(a) This Limited Power of Attorney authorizes, but does not require, the
Attorney-in-Fact to act at his or her discretion on information provided to such
Attorney-in-Fact without independent verification of such information;
(b) Any documents prepared or executed by the Attorney-in-Fact on behalf
of theundersigned pursuant to this Limited Power of Attorney will be in such
form and will contain such information as the Attorney-in-Fact, in his or her
discretion, deems necessary or desirable;
(c) Neither the Company nor the Attorney-in-Fact assumes any liability for
the undersigned's responsibility to comply with the requirements of Section 13
or Section 16 of the Exchange Act, any liability of the undersigned for any
failure to comply with such requirements, or any liability of the undersigned
for disgorgement of profits under Section 16(b) of the Exchange Act; and
(d) This Limited Power of Attorney does not relieve the undersigned from
responsibility for compliance with the undersigned's obligations under Section
13 or Section 16 of the Exchange Act, including, without limitation, the
reporting requirements under Section 13 or Section 16 of the Exchange Act.
The undersigned hereby grants to the Attorney-in-Fact full power and
authority to do and perform each and every act and thing requisite, necessary or
convenient to be done in connection with the foregoing, as fully, to all intents
and purposes, as the undersigned might or could do in person, hereby ratifying
and confirming all that the Attorney-in-Fact, or his or her substitute or
substitutes, shall lawfully do or cause to be done by authority of this Limited
Power of Attorney.
This Limited Power of Attorney shall remain in full force and effect until
the undersigned is no longer required to file Forms 4 or 5 or Schedule 13D or
13G with respect to the undersigned's holdings of and transactions in equity
securities of the Company, unless earlier revoked by the undersigned in a signed
writing delivered to the Attorney-in-Fact. This Limited Power of Attorney
revokes all previous powers of attorney with respect to the subject matter of
this Limited Power of Attorney.
IN WITNESS WHEREOF, the undersigned has executed this Limited Power of
Attorney as of September 11, 2015.
/s/ Michael J. Burdiek
------------------------------------
(Signature)
Print Name: Michael J. Burdiek
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