FORM 3
| Washington, D.C. 20549 |
OMB APPROVAL
OMB Number: 3235-0104 Estimated average burden hours per response... 0.5 |
| |
1. Name and Address of Reporting Person * Andreessen Horowitz Fund III, L.P. |
2. Date of Event Requiring Statement (MM/DD/YYYY)
| 3. Issuer Name and Ticker or Trading Symbol Cyngn, Inc. [CYN] |
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director ___X___ 10% Owner _____ Officer (give title below) _____ Other (specify below) | ||
5. If Amendment, Date Original Filed(MM/DD/YYYY) | 6. Individual or Joint/Group Filing(Check Applicable Line)
___ Form filed by One Reporting Person _X_ 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) |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
1. Title of Derivate Security (Instr. 4) | 2. Date Exercisable and Expiration Date (MM/DD/YYYY) | 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 | ||||
Series B Preferred Stock | (1) | (1) | Common Stock | 4947110 | (1) | I (2) | By Andreessen Horowitz Fund III, L.P. (2) |
Series C Preferred Stock | (1) | (1) | Common Stock | 287718 | (1) | I (2) | By Andreessen Horowitz Fund III, L.P. (2) |
Remarks: Scott Kupor has signed this Form 3 on behalf of Marc Andreessen and Benjamin Horowitz pursuant to a Power of Attorney already on file with the U.S. Securities and Exchange Commission. |
Reporting Owners | |||||
Reporting Owner Name / Address | |||||
Director | 10% Owner | Officer | Other | ||
Andreessen Horowitz Fund III, L.P. 2865 SAND HILL ROAD, SUITE 101 MENLO PARK, CA 94025 | X | ||||
AH Equity Partners III, L.L.C. 2865 SAND HILL ROAD SUITE 101 MENLO PARK, CA 94025 | X | ||||
Andreessen Marc L 2865 SAND HILL ROAD SUITE 101 MENLO PARK, CA 94025 | X | ||||
Andreessen Horowitz Fund III-A, L.P. 2865 SAND HILL ROAD SUITE 101 MENLO PARK, CA 94025 | X | ||||
Andreessen Horowitz Fund III-B, L.P. 2865 SAND HILL ROAD SUITE 101 MENLO PARK, CA 94025 | X | ||||
Andreessen Horowitz Fund III-Q, L.P. 2865 SAND HILL ROAD SUITE 101 MENLO PARK, CA 94025 | X | ||||
HOROWITZ BENJAMIN A 2865 SAND HILL ROAD SUITE 101 MENLO PARK, CA 94025 | X |
Signatures | ||
Andreessen Horowitz Fund III, L.P., By: AH Equity Partners III, L.L.C., Its: General Partner, By: /s/ Scott Kupor, Scott Kupor, Chief Operating Officer | 10/19/2021 | |
**Signature of Reporting Person | Date | |
AH Equity Partners III, L.L.C., By: /s/ Scott Kupor, Scott Kupor, Chief Operating Officer | 10/19/2021 | |
**Signature of Reporting Person | Date | |
/s/ Scott Kupor, Attorney-in-Fact for Marc L. Andreessen | 10/19/2021 | |
**Signature of Reporting Person | Date | |
Andreessen Horowitz Fund III-A, L.P., By: AH Equity Partners III, L.L.C., Its: General Partner, By: /s/ Scott Kupor, Scott Kupor, Chief Operating Officer | 10/19/2021 | |
**Signature of Reporting Person | Date | |
Andreessen Horowitz Fund III-B, L.P., By: AH Equity Partners III, L.L.C., Its: General Partner, By: /s/ Scott Kupor, Scott Kupor, Chief Operating Officer | 10/19/2021 | |
**Signature of Reporting Person | Date | |
Andreessen Horowitz Fund III-Q, L.P., By: AH Equity Partners III, L.L.C., Its: General Partner, By: /s/ Scott Kupor, Scott Kupor, Chief Operating Officer | 10/19/2021 | |
**Signature of Reporting Person | Date | |
/s/ Scott Kupor, Attorney-in-Fact for Benjamin A. Horowitz | 10/19/2021 | |
**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 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). |
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 control number. |