Form 3 MongoDB, Inc. For: Jul 10 Filed by: MERRIMAN DWIGHT A
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July 14, 2020 8:23 PM EDT
| FORM
3 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF
SECURITIES
Filed pursuant to Section 16(a) of the
Securities Exchange Act of 1934
or Section 30(h) of the Investment Company Act
of 1940
|
| OMB APPROVAL |
| OMB Number: |
3235-0104 |
| Expires: |
December 31, 2014 |
| Estimated average burden |
| hours per response: |
0.5 |
|
|
1. Name and Address of Reporting Person
*
| C/O MONGODB, INC. |
| 1633 BROADWAY, 38TH FLOOR |
(Street)
|
2. Date of Event Requiring Statement
(Month/Day/Year)
07/10/2020
|
3. Issuer Name
and
Ticker or Trading Symbol
MongoDB, Inc.
[
MDB
]
|
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
| X |
Director |
|
10% Owner |
|
Officer (give title below) |
|
Other (specify below) |
|
|
5. 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 |
|
| Table I - Non-Derivative Securities Beneficially Owned |
|---|
| 1. Title of Security (Instr.
4)
|
2.
Amount of Securities Beneficially Owned (Instr.
4)
|
3. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
|
4. Nature of Indirect Beneficial Ownership (Instr.
5)
|
|
Class A Common Stock
|
1,542,686
|
D
|
|
|
Class A Common Stock
|
604,896
|
I
|
By Trust
(1)
|
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
|
|---|
| 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: 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 |
|
Employee Stock Option (Right to Buy)
|
|
03/07/2023 |
Class A Common Stock
|
168,750
|
5.72
|
D
|
|
|
Employee Stock Option (Right to Buy)
|
|
02/28/2022 |
Class A Common Stock
|
16,875
|
1.96
|
D
|
|
| Explanation of Responses: |
|
|
| Remarks: |
| Exhibit 24 - Power of Attorney |
|
/s/ Sophie Hubscher, Attorney-in-Fact |
07/14/2020 |
|
** 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). |
| Note: File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure. |
| Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. |
POWER OF ATTORNEY
(For Executing Form ID and Forms 3, 4 and 5)
Know all by these presents, that the undersigned hereby constitutes and appoints each of Andrew
Stephens and Sophie Hubscher of MongoDB, Inc. (the "Company") and Nicole Brookshire and Alison
Haggerty of Cooley LLP with full power of substitution, signing individually, the undersigned's true and
lawful attorneys-in fact and agents to:
(1) Prepare, execute in the undersigned's name and on the undersigned's behalf, and
submit to the Securities and Exchange Commission (the "SEC") Form ID and Forms 3, 4 and 5 (including
amendments thereto and joint filing agreements in connection therewith) in accordance with Section 16(a)
of the Securities Exchange Act of 1934, as amended (the "Exchange Act") and the rules thereunder in the
undersigned's capacity as an officer, director or beneficial owner of more than 10% of a registered class of
securities of the Company;
(2) Do and perform any and all acts for and on behalf of the undersigned that may be
necessary or desirable to prepare and execute any such Form ID and Forms 3, 4 or 5 (including
amendments thereto and joint filing agreements in connection therewith) and timely file such forms with
the SEC and any stock exchange, self-regulatory association or any similar authority; and
(3) Take any other action of any type whatsoever in connection with the foregoing that,
in the opinion of such attorney-in-fact, may be of benefit to, in the best interest of, or legally required of
the undersigned, it being understood that the documents executed by the attorney-in-fact on behalf of the
undersigned pursuant to this Power of Attorney shall be in such form and shall contain such terms and
conditions as the attorney-in-fact may approve in the attorney-in-fact's discretion.
The undersigned hereby grants to each such attorney-in-fact full power and authority to do and
perform any and every act and thing whatsoever requisite, necessary, or proper to be done in the exercise
of any of the rights and powers herein granted, as fully to all intents and purposes as the undersigned
might or could do if personally present, with full power of substitution or revocation, hereby ratifying and
confirming all that such attorney-in-fact, or such attorney-in-fact's substitute or substitutes, shall lawfully
do or cause to be done by virtue of this power of attorney and the rights and powers herein granted. The
undersigned acknowledges that the foregoing attorneys-in-fact, and their substitutes, in serving in such
capacity at the request of the undersigned, are not assuming (nor is the Company assuming) any of the
undersigned's responsibilities to comply with Section 16 of the Exchange Act.
This Power of Attorney shall remain in full force and effect until the earliest to occur of (a) the
undersigned is no longer required to file Forms 3, 4 and 5 with respect to the undersigned's holdings of
and transactions in securities issued by the Company, (b) revocation by the undersigned in a signed
writing delivered to the Company and the foregoing attorneys-in fact or (c) as to any attorney-in-fact
individually, until such attorney-in-fact is no longer employed by the Company, or any of its subsidiaries,
or Cooley LLP, as applicable.
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be executed as
of the date written below.
Date: June 16, 2020
By: Dwight A. Merriman
Dwight A. Merriman
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