Initial Statement of Beneficial Ownership (3)
October 31 2017 - 6:53PM
Edgar (US Regulatory)
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FORM 3
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0104
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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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1. Name and Address of Reporting Person
*
Checketts Nathaniel L.
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2. Date of Event Requiring Statement (MM/DD/YYYY)
5/11/2017
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3. Issuer Name
and
Ticker or Trading Symbol
Veritone, Inc. [VERI]
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(Last)
(First)
(Middle)
C/O VERITONE, INC., 575 ANTON BOULEVARD
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4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
__
X
__ Director
_____ 10% Owner
_____ Officer (give title below)
_____ Other (specify below)
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(Street)
COSTA MESA, CA 92626
(City)
(State)
(Zip)
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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)
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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
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1.Title of Security
(Instr. 4)
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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 Derivate Security
(Instr. 4)
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2. Date Exercisable and Expiration Date
(MM/DD/YYYY)
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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 of Derivative Security: 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
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Expiration Date
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Title
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Amount or Number of Shares
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Stock Option (Right to Buy)
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(1)
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4/14/2026
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Common Stock
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15000
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$1.50
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D
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Explanation of Responses:
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(1)
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The option shares vest in 48 equal monthly installments commencing on August 7, 2014.
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Remarks:
Due to an administrative error, this Form 3 was not filed on May 11, 2017 (the effective date of the issuer's IPO), and has already been supplemented by a Form 4 filed on May 15, 2017 to reflect the reporting person's subsequent restricted stock unit award granted on May 11, 2017. As such, this Form 3 should be read in conjunction with the foregoing Form 4.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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Checketts Nathaniel L.
C/O VERITONE, INC.
575 ANTON BOULEVARD
COSTA MESA, CA 92626
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X
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Signatures
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/s/ Ellen S. Bancroft, Attorney-in-Fact
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10/31/2017
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 5(b)(v).
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**
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Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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Note:
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File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure.
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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.
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