SEC FORM 4 SEC Form 4
FORM 4 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

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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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
1. Name and Address of Reporting Person*
EFRUSY KEVIN

(Last) (First) (Middle)
3250 OLCOTT ST.

(Street)
SANTA CLARA CA 95054

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
Couchbase, Inc. [ BASE ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director 10% Owner
Officer (give title below) Other (specify below)
3. Date of Earliest Transaction (Month/Day/Year)
12/14/2023
4. 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
Rule 10b5-1(c) Transaction Indication

  
Check this box to indicate that a transaction was made pursuant to a contract, instruction or written plan that is intended to satisfy the affirmative defense conditions of Rule 10b5-1(c). See Instruction 10.
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security (Instr. 3) 2. Transaction Date (Month/Day/Year) 2A. Deemed Execution Date, if any (Month/Day/Year) 3. Transaction 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)
Code V Amount (A) or (D) Price
Common Stock 12/14/2023 J(1) 423,600 D $0.00 1,946,754 I By: Accel X L.P.(2)
Common Stock 12/14/2023 J(3) 32,100 D $0.00 147,515 I By: Accel X Strategic Partners L.P.(2)
Common Stock 12/14/2023 J(4) 44,300 D $0.00 203,580 I By: Accel Investors 2008 L.L.C.(2)
Common Stock 12/14/2023 J(5) 7,561 A $0.00 20,925 I By: The Efrusy Family Trust u/a/d 10/21/2005(6)
Common Stock 2,022,312 I By: Accel Growth Fund II L.P.(2)
Common Stock 146,484 I By: Accel Growth Fund II Strategic Partners L.P.(2)
Common Stock 217,110 I By: Accel Growth Fund Investors 2013 L.L.C.(2)
Common Stock 21,533(7) D
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 3) 2. Conversion or Exercise Price of Derivative Security 3. Transaction Date (Month/Day/Year) 3A. Deemed Execution Date, if any (Month/Day/Year) 4. Transaction 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 (Month/Day/Year) 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: 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
Explanation of Responses:
1. On December 14, 2023, Accel X L.P. distributed, for no consideration, 423,600 shares of Common Stock of the Issuer (the "Accel X LP Shares") to its limited partners and general partner, which shares were further distributed, representing each such partner's pro rata interest in such Accel X LP Shares. All of the aforementioned distributions were made in accordance with the exemptions afforded by Rules 16a-13 and 16a-9 of the Securities Exchange Act of 1934, as amended.
2. Accel X Associates L.L.C. ("A10A") is the General Partner of both Accel X L.P. and Accel X Strategic Partners L.P., and has the sole voting and investment power. Andrew G. Braccia, Kevin J. Efrusy, Sameer K. Gandhi, Ping Li, Tracy L. Sedlock and Richard P. Wong are the Managing Members of A10A and Accel Investors 2008 L.L.C., and therefore share the voting and investment powers. Accel Growth Fund II Associates L.L.C., or AGF2A, is the General Partner of both Accel Growth Fund II L.P. and Accel Growth Fund II Strategic Partners L.P., and has the sole voting and investment power. Andrew G. Braccia, Sameer K. Gandhi, Ping Li, Tracy L. Sedlock, Ryan J. Sweeney and Richard P. Wong are the Managing Members of AGF2A and Accel Growth Fund Investors 2013 L.L.C. and share such powers. Each person disclaims beneficial ownership except to the extent of their pecuniary interest therein. The address for all Accel entities listed above is 500 University Avenue, Palo Alto, California 94301.
3. On December 14, 2023, Accel X Strategic Partners L.P. ("A10SP") distributed, for no consideration, 32,100 shares of Common Stock of the Issuer (the "A10SP Shares") to its limited partners and general partner, which shares were further distributed, representing each such partner's pro rata interest in such A10SP Shares. All of the aforementioned distributions were made in accordance with the exemptions afforded by Rules 16a-13 and 16a-9 of the Securities Exchange Act of 1934, as amended.
4. On December 14, 2023, Accel Investors 2008 L.L.C. ("AI08") distributed for no consideration 44,300 shares of Common Stock of the Issuer (the "AI08 Shares") to its limited partners, representing each such partner's pro rata interest in such AI08 Shares. All of the aforementioned distributions were made in accordance with the exceptions afforded by Rules 16a-13 and 16a-9 of the Securities and Exchange Act of 1934, as amended.
5. Reflects shares of Common Stock of the Issuer as distributed by AI08 and A10A, for no consideration, to The Efrusy Family Trust u/a/d 10/21/2005 (the "Trust"), of which Mr. Efrusy is a Trustee.
6. Shares held by the Trust. The Reporting Person disclaims beneficial ownership over the securities reported herein except to the extent of his pecuniary interest therein, if any, and this report shall not be deemed an admission that the Reporting Person is the beneficial owner of such securities afforded by Rules 16a-13 and 16a-9 of the Securities Exchange Act of 1934, as amended.
7. Represents restricted stock units ("RSUs") of the Issuer. Each unit represents a contingent right to receive one share of the Issuer's common stock upon vesting. 11,659 of the RSUs are fully-vested and one hundred percent (100%) of the remaining 9,874 RSUs will vest on the earlier of (i) June 1, 2024 or (ii) the day prior to the Issuer's 2024 annual meeting of stockholders, subject to the Reporting Person's continued service through each such vesting date.
Remarks:
/s/ Margaret Chow, by Power of Attorney for Kevin Efrusy 12/18/2023
** 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 4 (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).
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