Statement of Changes in Beneficial Ownership (4)
August 30 2021 - 4:05PM
Edgar (US Regulatory)
FORM 4
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
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
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AKKARAJU SRINIVAS |
2. Issuer Name and Ticker or Trading Symbol
Jiya Acquisition Corp.
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JYAC
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__X__ Director __X__ 10% Owner _____ Officer (give title below) _____ Other (specify below)
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(Last)
(First)
(Middle)
628 MIDDLEFIELD ROAD |
3. Date of Earliest Transaction
(MM/DD/YYYY)
8/26/2021 |
(Street)
PALO ALTO, CA 94301
(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)
___ Form filed by One Reporting Person
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X
_ Form filed by More than One Reporting Person
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security (Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code (Instr. 8)
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4. Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)
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7. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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Amount
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(A) or (D)
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Price
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Table II - Derivative Securities 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 | 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 Following Reported Transaction(s) (Instr. 4) | 10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) | 11. Nature of Indirect Beneficial Ownership (Instr. 4) |
Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Class B Common Stock (1) | (1) | 8/26/2021 | | J (2) | | | 5000 (2) | (1) | (1) | Class A Common Stock | 5000 | (1)(2) | 2407447 (1)(3) | I | See Footnotes (3)(4) |
Explanation of Responses: |
(1) | The shares of Class B Common Stock of the Issuer ("Class B Shares") will automatically convert into shares of Class A Common Stock of the Issuer ("Class A Shares") on a one-for-one basis (subject to certain adjustments for stock splits, stock dividends, reorganizations, recapitalizations and similar transactions) concurrently with or immediately following the consummation of the Issuer's initial business combination, as described in the section entitled "Description of Securities" in the Issuer's Registration Statement on Form S-1 (File No. 333-249808) filed with the Securities and Exchange Commission on November 16, 2020. The Class B Shares have no expiration date. |
(2) | Reflects the transfer of 5,000 Class B Shares from Jiya Holding Company LLC ("Jiya Holdco") for no consideration ($0) to an individual providing advisory services to the Issuer. These Class B Shares will be subject to forfeiture by such advisor if the advisor ceases to provide services to the Issuer at any time before the consummation of the Issuer's initial business combination. |
(3) | Reflects the Class B Shares held by Jiya Holdco. This amount does not reflect the 30,000 Class B shares directly held by Dr. Srinivas Akkaraju M.D., Ph.D. |
(4) | Jiya HoldCo is wholly owned by Samsara BioCapital, L.P. ("Samsara LP"). Dr. Akkaraju has voting and dispositive control over the reported securities held by Jiya HoldCo via Dr. Akkaraju's control of Samsara LP's general partner, Samsara BioCapital GP, LLC. Each of the Reporting Persons disclaims beneficial ownership of the reported securities except to the extent of his or its pecuniary interest therein. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
AKKARAJU SRINIVAS 628 MIDDLEFIELD ROAD PALO ALTO, CA 94301 | X | X |
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Jiya Holding Co LLC 628 MIDDLEFIELD ROAD PALO ALTO, CA 94301 | X | X |
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Signatures
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By: /s/ Srinivas Akkaraju, By: Richard Van Doren, attorney-in-fact | | 8/26/2021 |
**Signature of Reporting Person | Date |
By: /s/ Jiya Holding Company LLC, By: Samsara BioCapital, L.P., its sole member, By: Samsara BioCapital GP, LLC, its General Partner, By: Richard Van Doren, its Chief Financial Officer | | 8/26/2021 |
**Signature of Reporting Person | Date |
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