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As Of Filer Filing As/For/On Docs:Pgs Issuer Agent 6/28/04 Brin Sergey 3 6/28/04 2:4 Google Inc R R Donnelley...Filer/FA
Document/Exhibit Description Pages Size 1: 3 Form 3 for Brin Dated 6/28/04 XML 7K 2: EX-24. Power of Attorney HTML 6K
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| 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, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940 |
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1. Name and Address of Reporting Person*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
6/28/04 |
3. Issuer Name and Ticker or Trading Symbol
Google Inc. [ NONE ] |
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| 4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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5. If Amendment, Date of Original Filed
(Month/Day/Year)
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6. Individual or Joint/Group Filing (Check Applicable Line)
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| 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) |
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Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities) |
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|---|---|---|---|---|---|---|---|
| 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 | ||||
| Series A Preferred Stock | 6/28/04 ( 1 ) | 6/28/04 ( 1 ) | Class B Common Stock | 290,304 | 0.0625 | D | |
| Class B Common Stock ( 2 ) | 6/28/04 ( 2 ) | 6/28/04 ( 2 ) | Class A Common Stock | 36,198,744 | 0 ( 2 ) | D | |
| Class B Common Stock ( 2 ) | 6/28/04 ( 2 ) | 6/28/04 ( 2 ) | Class A Common Stock | 2,000,000 | 0 ( 2 ) | I | By Trust |
| Explanation of Responses: |
| 1. Each share of Series A Preferred Stock shall be automatically converted into one share of Class B Common Stock upon the closing of the Issuer's initial public offering to occur at a later date and has no expiration date. |
| 2. Each share of Class B Common Stock is convertible into one share of Class A Common Stock at the option of the holder. |
| /s/ Matthew Tolland as attorney-in-fact | 6/28/04 | |
| ** 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 Number. | ||
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