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 of Derivative Security: 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 |
Shares of LIPO Investments (Canada), Inc.
(1)
|
Â
(2)
|
Â
(3)
|
Common Stock
|
6,818,182
|
$
(1)
|
D
|
Â
|
Shares of LIPO Investments (Canada), Inc.
(4)
|
Â
(2)
|
Â
(3)
|
Exchangeable shares of Lulu Canadian Holding, Inc.
|
19,516,615
|
$
(4)
|
D
|
Â
|
Series TS Preferred Stock
(5)
|
Â
(2)
|
Â
(3)
|
Common Stock
|
6,092,171
|
$
(5)
|
I
|
By LIPO Investments (USA), Inc.
|
* |
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). |
(1) |
These securities will be exchanged for common stock of the Issuer on the effective date of the Issuer's initial public offering in a corporate reorganization. |
(2) |
Immediately exercisable. |
(3) |
No expiration date. |
(4) |
These securities will be exchanged for exchangeable shares of Lulu Canadian Holding, Inc. on the effective date of the Issuer's initial public offering in a corporate reorganization. The exchangeable shares of Lulu Canadian Holding, Inc. will be exchangeable for shares of the Issuer's common stock on a 1-for-1 basis. |
(5) |
These securities will be exchanged for shares of common stock of the Issuer on the effective date of the Issuer's initial public offering in a corporate reorganization. |