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
OMB APPROVAL
OMB Number: 3235-0104
Estimated average burden
hours per response: 0.5
1. Name and Address of Reporting Person*
Chen Mo

(Last) (First) (Middle)
9191 TOWNE CENTRE DRIVE, STE 600

(Street)
SAN DIEGO CA 92122

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
04/14/2021
3. Issuer Name and Ticker or Trading Symbol
TuSimple Holdings Inc. [ TSP ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director X 10% Owner
X Officer (give title below) Other (specify below)
Executive Chairman
5. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
Form filed by One Reporting Person
X 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(1) 20,000,000 I By corporation(2)
Common Stock(1) 75,000 I By corporation(3)
Common Stock(1) 6,292,314 I By corporation(4)
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
1. Name and Address of Reporting Person*
Chen Mo

(Last) (First) (Middle)
9191 TOWNE CENTRE DRIVE, STE 600

(Street)
SAN DIEGO CA 92122

(City) (State) (Zip)
1. Name and Address of Reporting Person*
Gray Jade Holding Ltd

(Last) (First) (Middle)
9191 TOWNE CENTRE DRIVE, STE 600

(Street)
SAN DIEGO CA 92122

(City) (State) (Zip)
Explanation of Responses:
1. Immediately prior to the completion of the Issuer's initial public offering of Class A Common Stock, each share of Common Stock shall be reclassified into one share of Class A Common Stock and certain of such shares of Class A Common Stock shall be exchanged at a 1:1 ratio for shares of Class B Common Stock.
2. The shares are held by Gray Jade Holding Limited, a company incorporated in British Virgin Islands and beneficially owned by The Chen Family Trust, of which the Reporting Person is trustee.
3. The shares are held by THC International Limited, a company incorporated in British Virgin Islands and beneficially owned by the Reporting Person.
4. The shares are held by Brown Jade Holding Limited, a company incorporated in British Virgin Islands and beneficially owned by the Reporting Person.
Remarks:
Mo Chen, By: /s/ James Mullen, Attorney-in-Fact 04/14/2021
Gray Jade Holding Limited, By: /s/ James Mullen, Attorney-in-Fact 04/14/2021
** 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.