Annual Statement of Changes in Beneficial Ownership (5)
January 07 2021 - 01:14PM
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
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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 * McGarvey Casey
Kale |
2. Issuer Name and Ticker or Trading
SymbolPurple Innovation, Inc. [PRPL] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)_____
Director _____
10% Owner
__X__ Officer (give title
below) _____ Other
(specify below)
Chief Legal Officer |
(Last)
(First)
(Middle)
C/O PURPLE INNOVATION, INC., 4100 NORTH CHAPEL RIDGE ROAD,
SUITE 200 |
3. Statement for Issuer's Fiscal Year Ended
(MM/DD/YYYY)
12/31/2020
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(Street)
LEHI, UT 84043
(City)
(State)
(Zip)
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4. If Amendment, Date Original
Filed(MM/DD/YYYY)
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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 |
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 |
Class B Common Stock |
$0 |
12/30/2020 |
|
G |
|
22258 |
(1) |
(1) |
Class A Common Stock |
22258 |
$0 |
150000 |
D |
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Explanation of
Responses: |
(1) |
The shares of Class B Common
Stock are convertible at any time (together with a corresponding
number of Class B Units of Purple Innovation LLC) for shares of the
Issuer's Class A Common Stock, par value $0.0001 per share, as
described under the heading "Exchange Agreement" in the Issuer's
Current Report on Form 8-K filed February 8, 2018, as
amended. |
Reporting
Owners
|
Reporting Owner Name / Address |
Relationships
|
Director |
10% Owner |
Officer |
Other |
McGarvey Casey Kale
C/O PURPLE INNOVATION, INC.
4100 NORTH CHAPEL RIDGE ROAD, SUITE 200
LEHI, UT 84043 |
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|
Chief Legal Officer |
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Signatures
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/s/ Casey K. McGarvey |
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1/7/2021 |
**Signature of
Reporting Person |
Date |