1. Name and Address of Reporting Person * |
Â
TOLAN MARY A |
|
2. Date of Event Requiring Statement (Month/Day/Year) 05/19/2010 |
3. Issuer Name and Ticker or Trading Symbol Accretive Health, Inc. [AH]
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C/O ACCRETIVE HEALTH, INC., 401 NORTH MICHIGAN AVENUE, SUITE 2700 |
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
__X__ Director |
__X__ 10% Owner |
__X__ Officer (give title below) |
_____ Other (specify below) |
Founder, President and CEO |
|
5. If Amendment, Date Original Filed(Month/Day/Year)
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CHICAGO, IL 60611 |
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) |
Common Stock
|
8,503,416
|
D
|
Â
|
Common Stock
|
2,587,200
|
I
|
By the Tolan Family Trust
(1)
|
Common Stock
|
646,800
|
I
|
By the Tolan Gamma Trust
(1)
|
|
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 |
Series A Convertible Preferred Stock
|
Â
(2)
|
Â
(2)
|
Common Stock
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1,316,851
|
$
(2)
|
D
|
Â
|
Series D Convertible Preferred Stock
|
Â
(3)
|
Â
(3)
|
Common Stock
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874,148
|
$
(3)
|
D
|
Â
|
Stock Option (Right to Buy)
|
Â
(4)
|
02/03/2020 |
Common Stock
|
1,176,000
|
$
14.71
|
D
|
Â
|
* |
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) |
The shares are held in a trust, the beneficiaries of which are members of Ms. Tolan's immediate family. Members of Ms. Tolan's immediate family are trustees of the trust. |
(2) |
Each share of Series A Convertible Preferred Stock represented herein is immediately convertible, and will automatically convert upon the closing of the Issuer's initial public offering, into 1,201.5068 shares of common stock, par value $0.01 per share, of the Issuer, and has no expiration date. |
(3) |
Each share of Series D Convertible Preferred Stock represented herein is immediately convertible, and will automatically convert upon the closing of the Issuer's initial public offering, into 3.92 shares of common stock, par value $0.01 per share, of the Issuer, and has no expiration date. |
(4) |
The shares subject to the option vest in four equal annual installments beginning on February 3, 2011, and the option can be exercised immediately upon grant, provided that upon exercise the shares issued are subject to the same vesting and repurchase provisions that applied before exercise. |