Annual Statement of Changes in Beneficial Ownership (5)
February 12 2021 - 06:54PM
Edgar (US Regulatory)
FORM 5
[ ]
Check this box if no longer subject to Section 16. Form 4 or Form 5
obligations may continue. See Instruction 1(b).
[ ] Form 3 Holdings Reported
[ ] Form 4 Transactions Reported
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL
OWNERSHIP OF SECURITIES
|
OMB APPROVAL
OMB Number: 3235-0362
Estimated average burden
hours per response... 1.0 |
|
Filed pursuant to Section 16(a) of the
Securities Exchange Act of 1934 or Section 30(h) of the Investment
Company Act of 1940
|
|
1. Name
and Address of Reporting Person * Steelberg
Ryan |
2. Issuer Name and Ticker or Trading
SymbolVeritone, Inc. [VERI] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)__X__
Director __X__
10% Owner
__X__ Officer (give title
below) _____ Other
(specify below)
President |
(Last)
(First)
(Middle)
C/O VERITONE, INC., 575 ANTON BOULEVARD |
3. Statement for Issuer's Fiscal Year Ended
(MM/DD/YYYY)
12/31/2020
|
(Street)
COSTA MESA, CA 92626
(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 |
Table I - Non-Derivative Securities Acquired, Disposed of, or
Beneficially Owned
|
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 |
12/8/2020 |
|
G (1) |
100000 |
D |
$0 |
32097 |
I |
Held by Living Trust (2) |
Common Stock |
|
|
|
|
|
|
215921 |
I |
Held by Steel Veritone Fund I,
LLC (3) |
Common Stock |
|
|
|
|
|
|
212633 |
D |
|
Common Stock |
|
|
|
|
|
|
2003349 |
I |
Held by RVH, LLC (4) |
Table II - Derivative Securities Acquired, Disposed of, or
Beneficially Owned (e.g., puts, calls, warrants, options,
convertible securities)
|
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) |
Shares were transferred by
reporting person, as trustee of his living trust, by gift to an
irrevocable trust for the benefit of his children. Reporting person
no longer has any pecuniary interest in, or voting or dispositive
control over, such shares. |
(2) |
Shares are held by reporting
person as trustee of a living trust. |
(3) |
Shares are held by Steel
Veritone Fund I, LLC ("SVF"). The grantor trust of reporting person
owns 50% of the membership interests in SVF and, as such, reporting
person may be deemed a beneficial owner of such shares. Reporting
person disclaims beneficial ownership of such shares, except to the
extent of his pecuniary interest therein. |
(4) |
Shares are held by RVH, LLC,
a limited liability company. Reporting person is the sole manager
and member of RVH, LLC. |
Reporting
Owners
|
Reporting Owner Name / Address |
Relationships
|
Director |
10% Owner |
Officer |
Other |
Steelberg Ryan
C/O VERITONE, INC.
575 ANTON BOULEVARD
COSTA MESA, CA 92626 |
X |
X |
President |
|
Signatures
|
/s/Jeffrey B. Coyne, as attorney-in-fact for
reporting person |
|
2/12/2021 |
**Signature of
Reporting Person |
Date |