SEC Form 3
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
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1. Name and Address of Reporting Person*
Sekar Kiren

(Last) (First) (Middle)
C/O SAMSARA INC. 350 RHODE ISLAND STREET
4TH FLOOR, SOUTH BUILDING

(Street)
SAN FRANCISCO CA 94103

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
12/14/2021
3. Issuer Name and Ticker or Trading Symbol
Samsara Inc. [ IOT ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director 10% Owner
X Officer (give title below) Other (specify below)
See remarks
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)
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
Stock Option (right to buy) (1) 05/08/2029 Class B Common Stock 27,537 $3.51 D
Stock Option (right to buy) (2) 05/08/2029 Class B Common Stock 314,483 $3.51 D
Class B Common Stock (3) (3) Class A Common Stock 1,300,000 (3) I See footnote(4)
Class B Common Stock (3) (3) Class A Common Stock 4,375,914 (3) I See footnote(5)
Explanation of Responses:
1. 1/48 of the total shares subject to the Option vested on March 4, 2019 and thereafter 1/48 of the shares subject to the Option vest each month on the same day of the month.
2. 1/48 of the total shares subject to the Option vested on July 4, 2019 and thereafter 1/48 of the shares subject to the Option vest each month on the same day of the month.
3. The Class B Common Stock is convertible at any time, at the holder's election, into Class A Common Stock on a 1:1 basis.
4. Consists of shares held by Jordan Park Trust Company, LLC, Trustee of The Sekar Family Irrevocable Trust u/a/d 1/26/2021, over which Mr. Sekar has voting or investment power.
5. Consists of shares held by KRS and CCS, Co-Trustees of The Sekar Family Revocable Trust u/a/d 5/20/2013, over which Mr. Sekar has voting or investment power.
Remarks:
Executive Vice President, Chief Product Officer Power of Attorney
/s/ Adam Eltoukhy, attorney-in-fact on behalf of Kiren Sekar 12/14/2021
** 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.
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