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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1. Name and Address of Reporting Person*
Menezes Ronald

(Last) (First) (Middle)
420 S. FAIRVIEW AVENUE
SUITE 200

(Street)
SANTA BARBARA CA 93117

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
11/10/2020
3. Issuer Name and Ticker or Trading Symbol
Sientra, Inc. [ SIEN ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director 10% Owner
X Officer (give title below) Other (specify below)
President and CEO
5. If Amendment, Date of Original Filed (Month/Day/Year)
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 Beneficially Owned
1. Title of Security (Instr. 4) 2. Amount of Securities Beneficially Owned (Instr. 4) 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 4. Nature of Indirect Beneficial Ownership (Instr. 5)
Common Stock 500,000(1) D
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 4) 2. Date Exercisable and Expiration Date (Month/Day/Year) 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) 4. Conversion or Exercise Price of Derivative Security 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 6. Nature of Indirect Beneficial Ownership (Instr. 5)
Date Exercisable Expiration Date Title Amount or Number of Shares
Employee Stock Option (Right to Buy) (2) 11/08/2030 Common Stock 500,000 4.41 D
Performance Rights (3) 11/08/2030 Common Stock 500,000 0.00 D
Explanation of Responses:
1. Each restricted stock unit represents a contingent right to receive one share of Sientra, Inc. Class A Common Stock. The restricted stock units shall vest as follows: 125,000 on the first anniversary of the grant date; 125,000, on the second anniversary of the grant date; 125,000 on the third anniversary of the grant date; and 125,000 on the fourth anniversary of the grant date.
2. The option shall vest as follows: 125,000 common shares on the first anniversary of the grant date; the remaining 375,000 common sharers shall vest in thirty-six (36) equal consecutive monthly installments beginning on the thirteenth (13th) month following the grant date.
3. Each performance right restricted stock unit ("PRSU") represents a contingent right to receive one share of common stock of Sientra, Inc. The PRSUs shall vest as follows: (i) 125,000 PRSUs shall vest on the first business day following the 30-day volume weighted average price of the Company's common stock (the "Target VWAP") exceeding $10 per share; (ii) 125,000 PRSU's shall vest on the first business day following the Target VWAP exceeding $15 per share; (iii) 125,000 shall vest on the first business day following the Target VWAP exceeding $20 per share; and (iv) 125,000 shall vest on the first business day following the Target VWAP exceeding $25 per share.
Remarks:
Exhibit 24.1 - Power of Attorney
/s/ Ronald Menezes, by Oliver Bennett, as Attorney-in-Fact 11/13/2020
** 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.
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