Annual Statement of Changes in Beneficial Ownership (5)
March 13 2020 - 5:48PM
Edgar (US Regulatory)
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
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Form 3 Holdings Reported
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Form 4 Transactions Reported
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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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
*
Wolberg Kirsten O. | 2. Issuer Name and Ticker or Trading SymbolDOCUSIGN, INC. [DOCU] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
_____ Director _____ 10% Owner __X__ Officer (give title below) _____ Other (specify below) Chief Technology & Ops Officer |
(Last)
(First)
(Middle)
C/O DOCUSIGN, INC., 221 MAIN STREET, SUITE 1550 | 3. Statement for Issuer's Fiscal Year Ended (MM/DD/YYYY) 1/31/2020 |
(Street)
SAN FRANCISCO, CA 94105
(City)
(State)
(Zip)
| 4. If Amendment, Date Original Filed(MM/DD/YYYY) | 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 Acquired, Disposed of, or Beneficially Owned
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1.Title of Security (Instr. 3) | 2. Trans. Date | 2A. Deemed Execution Date, if any | 3. Trans. Code (Instr. 8) | 4. Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) | 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) | 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 7. Nature of Indirect Beneficial Ownership (Instr. 4) |
Amount | (A) or (D) | Price |
Common Stock | 1/10/2020 | | G | 486 | D | $0 | 145300 | D | |
Common Stock | 1/10/2020 | | G (1) | 486 | A | $0 | 486 | I | By First Child's Trust |
Common Stock | 1/10/2020 | | G | 486 | D | $0 | 144814 | D | |
Common Stock | 1/31/2020 | | G (2) | 486 | A | $0 | 486 | I | By Second Child's Trust |
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security (Instr. 3) | 2. Conversion or Exercise Price of Derivative Security | 3. Trans. Date | 3A. Deemed Execution Date, if any | 4. Trans. Code (Instr. 8) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) | 6. Date Exercisable and Expiration Date (MM/DD/YYYY) | 7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4) | 8. Price of Derivative Security (Instr. 5) | 9. Number of Derivative Securities Beneficially Owned at End of Issuer's Fiscal Year (Instr. 4) | 10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) | 11. Nature of Indirect Beneficial Ownership (Instr. 4) |
(A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Explanation of Responses: |
(1) | This transaction involved a gift of securities by the Reporting Person to a trust for the benefit of her first child, who shares the Reporting Person's household. The Reporting Person disclaims beneficial ownership of the shares held in the first child's trust, and this report should not be deemed an admission that the Reporting Person is the beneficial owner of the shares held in the trust for purposes of Section 16 or for any other purpose. |
(2) | This transaction involved a gift of securities by the Reporting Person to a trust for the benefit of her second child, who shares the Reporting Person's household. The Reporting Person disclaims beneficial ownership of the shares held in the second child's trust, and this report should not be deemed an admission that the Reporting Person is the beneficial owner of the shares held in the trust for purposes of Section 16 or for any other purpose. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Wolberg Kirsten O. C/O DOCUSIGN, INC. 221 MAIN STREET, SUITE 1550 SAN FRANCISCO, CA 94105 |
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| Chief Technology & Ops Officer |
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Signatures
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/s/ Apple Palarca, Attorney-in-fact | | 3/13/2020 |
**Signature of Reporting Person | Date |
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