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 PERSONALIS, INC. |
| 1330 O'BRIEN DRIVE |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
02/17/2022
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3. Issuer Name and Ticker or Trading Symbol
Personalis, Inc.
[ PSNL ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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Director |
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10% Owner |
| X |
Officer (give title below) |
|
Other (specify below) |
| General Counsel |
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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 |
|
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 |
45,639
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D |
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| Common Stock |
11,475
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D |
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| Common Stock |
25,000
|
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 |
| Stock Option (Right to Buy) |
04/29/2021
|
04/29/2030 |
Common Stock |
100,000 |
10.81 |
D |
|
| Stock Option (Right to Buy) |
06/15/2021
|
05/15/2031 |
Common Stock |
25,000 |
19.74 |
D |
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| Explanation of Responses: |
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|
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| Remarks: |
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/s/ Aaron Tachibana, Attorney-in-Fact |
03/08/2022 |
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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 16 REPORTING OBLIGATIONS
Know all by these presents, that the undersigned
hereby constitutes and appoints each of John West,
Aaron Tachibana, Michael Tenta, Allison Peth, Jacob Hanna,
Laura Berezin and Kristin Peardon, with full power of substitution,
signing individually, the undersigneds true and lawful
attorneys-in fact and agents to:
(1) execute for and on behalf of the undersigned, in the
undersigneds capacity as an officer, director or beneficial
owner of more than 10% of a registered class of securities of
Personalis, Inc., Forms 3, 4, and 5 (including any amendments thereto),
relating to the securities of Personalis, Inc., in accordance
with Section 16(a) of the Securities Exchange Act of 1934, as
amended (the "Exchange Act") and the rules thereunder and a Form ID,
Uniform Application for Access Codes to File on EDGAR;
(2) do and perform any and all acts for and on behalf of the
undersigned that may be necessary or desirable to execute such
Forms 3, 4, or 5, or Form ID (including any amendments thereto)
and timely file such forms with the United States Securities
and Exchange Commission and any stock exchange or similar
authority; and
(3) take any other action of any nature whatsoever in connection
with the foregoing which, in the opinion of such attorney-in-fact,
may be of benefit, 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-facts discretion.
The undersigned hereby grants to each such attorney-in-fact full
power and authority to do and perform any 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 or revocation, hereby
ratifying and confirming all that such attorney-in-fact, or such
attorney-in-facts 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 the foregoing
attorneys-in-fact, in serving in such capacity at the request of the
undersigned, are not assuming, nor is Personalis, Inc. assuming,
any of the undersigneds responsibilities to comply with Section 16
of the Exchange Act.
This Power of Attorney shall remain in full force and effect
until the earliest to occur of (a) the undersigned is no longer
required to file Forms 3, 4 and 5 with respect to the undersigneds
holdings of and transactions in securities issued by Personalis, Inc.,
(b) revocation by the undersigned in a signed writing delivered to the
foregoing attorneys-in-fact or (c) as to any attorney-in-fact individually,
until such attorney-in-fact is no longer employed by Personalis, Inc.
or Cooley LLP.
The undersigned has caused this Power of Attorney to be
executed as of March 4, 2022.
Stephen Michael Moore
