Capso Vision Inc.

07/08/2025 | Press release | Distributed by Public on 07/08/2025 12:40

Statement of Changes in Beneficial Ownership (Form 4)

FORM 4
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
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.
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN 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: 3235-0287
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(Print or Type Responses)
1. Name and Address of Reporting Person *
HARARI ELIYAHOU ET AL
2. Issuer Name and Ticker or Trading Symbol
CapsoVision, Inc [CV]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
_____ Director __X__ 10% Owner
_____ Officer (give title below) _____ Other (specify below)
(Last) (First) (Middle)
140 CASPIAN COURT, C/O SANDISK CORP
3. Date of Earliest Transaction (Month/Day/Year)
07/03/2025
(Street)
SUNNYVALE, CA 94089
4. If Amendment, Date 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
(City) (State) (Zip)
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 07/03/2025 C 3,186,904 A (1) 3,186,904(1) I By trust.(2)
Common Stock 07/03/2025 C 517,759 A (1) 517,759(1) I By trust.(3)
Common Stock 07/03/2025 C 517,759 A (1) 517,759(1) I By trust.(4)
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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. SEC 1474 (9-02)
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 Underlying Securities
(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 of Derivative Security: 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
Series D-1 Preferred Stock (1) 07/03/2025 C 222,222 (1) (1) Common Stock 66,733(1) $ 0 0 I By trust.(2)
Series D-2 Preferred Stock (1) 07/03/2025 C 934,588 (1) (1) Common Stock 280,657(1) $ 0 0 I By trust.(2)
Series E Preferred Stock (1) 07/03/2025 C 434,782 (1) (1) Common Stock 130,565(1) $ 0 0 I By trust.(2)
Series F-1 Preferred Stock (1) 07/03/2025 C 434,783 (1) (1) Common Stock 130,565(1) $ 0 0 I By trust.(2)
Series F-2 Preferred Stock (1) 07/03/2025 C 2,000,000 (1) (1) Common Stock 600,601(1) $ 0 0 I By trust.(2)
Series G Preferred Stock (1) 07/03/2025 C 740,741 (1) (1) Common Stock 222,445(1) $ 0 0 I By trust.(2)
Series G-1 Preferred Stock (1) 07/03/2025 C 1,206,898 (1) (1) Common Stock 362,432(1) $ 0 0 I By trust.(2)
Series H Preferred Stock (1) 07/03/2025 C 4,638,377 (1) (1) Common Stock 1,392,906(1) $ 0 0 I By trust.(2)
Series H Preferred Stock (1) 07/03/2025 C 1,724,139 (1) (1) Common Stock 517,759(1) $ 0 0 I By trust.(3)
Series H Preferred Stock (1) 07/03/2025 C 1,724,139 (1) (1) Common Stock 517,759(1) $ 0 0 I By trust.(4)

Reporting Owners

Reporting Owner Name / Address Relationships
Director 10% Owner Officer Other
HARARI ELIYAHOU ET AL
140 CASPIAN COURT
C/O SANDISK CORP
SUNNYVALE, CA 94089
X

Signatures

/s/ Peter Bergman, Attorney-in-Fact for Eliyahou Harari 07/07/2025
**Signature of Reporting Person Date

Explanation of Responses:

* 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).
(1) Each share of Series D-1 preferred stock, Series D-2 preferred stock, Series E preferred stock, Series F-1 preferred stock, Series F-2 preferred stock, Series G preferred stock, Series G-1 preferred stock, and Series H preferred stock automatically converted into approximately 0.3003 shares of common stock of the Issuer upon the closing of the initial public offering of the Issuer. The number of shares reported herein gives effect to a 1-for-3.33 reverse stock split of the common stock of the Issuer effected by the Issuer on July 2, 2025 in connection with its initial public offering.
(2) The securities are held by the Harari Family Trust, for which the Reporting Person, together with his wife, are trustees.
(3) The securities are held by Harari 2010 Children Remainder Trust - MHG, for which the Reporting Person, together with his wife, are trustees.
(4) The securities are held by Harari 2010 Children Remainder Trust - DAH, for which the Reporting Person, together with his wife, are trustees.
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. Potential persons who are to respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB number.
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