Statement of Ownership (sc 13g)
February 13 2017 - 5:04PM
Edgar (US Regulatory)
SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
Schedule 13G
(Rule 13d-102)
INFORMATION TO BE INCLUDED IN STATEMENTS
FILED PURSUANT TO RULES 13d-1 (b), (c) AND (d)
AND AMENDMENTS THERETO FILED PURSUANT TO 13d-2 (b)
(Amendment No. _____)*
Coupa Software Incorporated
(Name of Issuer)
Common Stock
(Title of Class of Securities)
22266L106
(CUSIP Number)
December 31, 2016
(Date of Event Which Requires Filing of
this Statement)
Check the appropriate box to designate the rule pursuant to
which this Schedule is filed:
*The remainder of this cover page shall be filled out for a
reporting person’s initial filing on this form with respect to the subject class of securities, and for any subsequent amendment
containing information which would alter disclosures provided in a prior cover page.
The information required on the remainder of this cover page
shall not be deemed to be “filed” for the purpose of Section 18 of the Securities Exchange Act of 1934 (“Act”)
or otherwise subject to the liabilities of that section of the Act but shall be subject to all other provisions of the Act (however,
see the Notes).
(Continued on following
pages)
1
|
NAME OF REPORTING PERSONS Robert Bernshteyn
|
2
|
CHECK THE APPROPRIATE BOX IF A MEMBER OF A GROUP
|
(a)
¨
(b)
¨
|
3
|
SEC USE ONLY
|
4
|
CITIZENSHIP OR PLACE OF ORGANIZATION
USA
|
NUMBER OF
SHARES
BENEFICIALLY
OWNED BY EACH REPORTING
PERSON
WITH
|
5
|
SOLE VOTING POWER
2,552,454 (1)
|
6
|
SHARED VOTING POWER
0
|
7
|
SOLE DISPOSITIVE POWER
2,552,454 (1)
|
8
|
SHARED DISPOSITIVE POWER
0
|
9
|
AGGREGATE AMOUNT BENEFICIALLY OWNED BY EACH
REPORTING PERSON
|
2,552,454 (1)
|
10
|
CHECK BOX IF THE AGGREGATE AMOUNT IN ROW (9)
EXCLUDES CERTAIN SHARES
|
¨
|
11
|
PERCENT OF CLASS REPRESENTED BY AMOUNT IN ROW 9
|
4.92 (2)
|
12
|
TYPE OF REPORTING PERSON
|
IN
|
|
(1)
|
Includes 1,698,177 shares issuable upon exercise of stock options issued to the Reporting Person and exercisable within 60
days of December 31, 2016.
|
|
(2)
|
Based on 51,837,997 shares of common stock outstanding as of December 31, 2016, which includes shares of common stock issuable
to the Reporting Person pursuant to stock options exercisable within 60 days of December 31, 2016.
|
|
ITEM 1(A).
|
NAME OF ISSUER
|
Coupa Software Incorporated
|
ITEM 1(B).
|
ADDRESS OF ISSUER’S PRINCIPAL EXECUTIVE OFFICES
1855 S. Grant Street
|
San Mateo, CA 94402
|
ITEM 2(A).
|
NAME OF PERSONS FILING
Robert Bernshteyn
|
|
ITEM 2(B).
|
ADDRESS OF PRINCIPAL OFFICE
|
The address for each of the Reporting Persons
is:
c/o Coupa Software Incorporated
1855 S. Grant Street
San Mateo, CA 94402
USA
|
ITEM 2(D).
|
TITLE OF CLASS OF SECURITIES
Common Stock, $0.0001 par value
|
|
ITEM 2(D)
|
CUSIP NUMBER
22266L106
|
|
ITEM 3.
|
If this statement
is filed pursuant to Rule 13d-1(b), or 13d-2(b) or (c), check whether the person filing is a:
Not applicable.
|
The following information with respect
to the ownership of the ordinary shares of the Issuer by the persons filing this Statement is provided as of December 31,
2016:
|
(a)
|
Amount beneficially owned
:
See Row 9 of cover page.
|
|
(b)
|
Percent of Class
:
See Row 11 of cover page.
|
|
(c)
|
Number of shares as to which such person has
:
|
|
(i)
|
Sole power to vote or to direct the vote
:
See Row 5 of cover page.
|
|
(ii)
|
Shared power to vote or to direct the vote
:
|
See Row 6 of cover page.
|
(iii)
|
Sole power to dispose or to direct the disposition of
:
|
See Row 7 of cover page.
|
(iv)
|
Shared power to dispose or to direct the disposition of
:
See Row 8 of cover page.
|
|
ITEM 5.
|
OWNERSHIP OF FIVE PERCENT OR LESS OF A CLASS
If this statement is being filed to report the fact that as of the date hereof the reporting person has ceased to be the beneficial
owner or more than five percent of the class of securities, check the following box:
x
.
|
|
ITEM 6.
|
OWNERSHIP OF MORE THAN FIVE PERCENT ON BEHALF OF ANOTHER
PERSON
.
Not applicable.
|
|
ITEM 7.
|
IDENTIFICATION AND CLASSIFICATION OF THE SUBSIDIARY
WHICH ACQUIRED THE SECURITY BEING REPORTED ON BY THE PARENT HOLDING COMPANY
Not applicable.
|
|
ITEM 8.
|
IDENTIFICATION AND CLASSIFICATION OF MEMBERS OF THE
GROUP
.
Not applicable
|
|
ITEM 9.
|
NOTICE OF DISSOLUTION OF GROUP
.
Not applicable
|
|
ITEM 10.
|
CERTIFICATION
.
Not applicable
|
SIGNATURES
After reasonable inquiry and to the best of
my knowledge and belief, I certify that the information set forth in this statement is true, complete and correct.
Date: February 13, 2017
|
/s/Robert Bernshteyn
|
|
|
Robert Bernshteyn
|
|
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