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Ownership Document
|
| Schema Version: X0202 |
| Document Type: 3 |
| Period of Report: 6/28/04 |
| No Securities Owned: 0 |
| Issuer: |
| Issuer CIK: 1288776 |
| Issuer Name: Google Inc. |
| Issuer Trading Symbol: NONE |
| Reporting Owner: |
| Reporting Owner ID: |
| | Owner CIK: 1295032 |
| | Owner Name: Brin Sergey |
| Reporting Owner Address: |
| | Owner Street 1: C/O GOOGLE INC. |
| | Owner Street 2: 1600 AMPHITHEATRE PARKWAY |
| | Owner City: MOUNTAIN VIEW |
| | Owner State: CA |
| | Owner ZIP Code: 94043 |
| | Owner State Description: |
| Reporting Owner Relationship: |
| | Is Director? Yes |
| | Is Officer? Yes |
| | Is Ten Percent Owner? Yes |
| | Is Other? No |
| | Officer Title: President, Tech, Asst. Secty |
| Derivative Table: |
| Derivative Holding: |
| | Security Title: |
| | | Value: Series A Preferred Stock |
| | Conversion or Exercise Price: |
| | | Value: 0.0625 |
| | Exercise Date: |
| | | Value: 6/28/04 |
| | | Footnote ID: F1 |
| | Expiration Date: |
| | | Value: 6/28/04 |
| | | Footnote ID: F1 |
| | Underlying Security: |
| | | Underlying Security Title: |
| Value: Class B Common Stock |
| | | Underlying Security Shares: |
| Value: 290,304 |
| | Ownership Nature: |
| | | Direct or Indirect Ownership: |
| Value: D |
| Derivative Holding: |
| | Security Title: |
| | | Value: Class B Common Stock |
| | | Footnote ID: F2 |
| | Conversion or Exercise Price: |
| | | Value: 0.00 |
| | | Footnote ID: F2 |
| | Exercise Date: |
| | | Value: 6/28/04 |
| | | Footnote ID: F2 |
| | Expiration Date: |
| | | Value: 6/28/04 |
| | | Footnote ID: F2 |
| | Underlying Security: |
| | | Underlying Security Title: |
| Value: Class A Common Stock |
| | | Underlying Security Shares: |
| Value: 36,198,744 |
| | Ownership Nature: |
| | | Direct or Indirect Ownership: |
| Value: D |
| Derivative Holding: |
| | Security Title: |
| | | Value: Class B Common Stock |
| | | Footnote ID: F2 |
| | Conversion or Exercise Price: |
| | | Value: 0.00 |
| | | Footnote ID: F2 |
| | Exercise Date: |
| | | Value: 6/28/04 |
| | | Footnote ID: F2 |
| | Expiration Date: |
| | | Value: 6/28/04 |
| | | Footnote ID: F2 |
| | Underlying Security: |
| | | Underlying Security Title: |
| Value: Class A Common Stock |
| | | Underlying Security Shares: |
| Value: 2,000,000 |
| | Ownership Nature: |
| | | Direct or Indirect Ownership: |
| Value: I |
| | | Nature of Ownership: |
| Value: By Trust |
| Footnotes: |
| Footnote - F1: 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. |
| Footnote - F2: Each share of Class B Common Stock is convertible into one share of Class A Common Stock at the option of the holder. |
| Owner Signature: |
| Signature Name: /s/ Matthew Tolland as attorney-in-fact |
| Signature Date: 6/28/04 |
