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Page Lawrence – ‘3’ for 6/28/04 re: Google Inc.

On:  Monday, 6/28/04, at 7:17pm ET   ·   For:  6/28/04   ·   As:  Director, Officer and 10% Owner   ·   Accession #:  1181431-4-32636   ·   File #:  0-50726

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  As Of                Filer                Filing    For·On·As Docs:Size              Issuer               Agent

 6/28/04  Page Lawrence                     3          D,O,%Owner  2:8K   Google Inc.                       R R Donnelley...Filer/FA

Initial Statement of Beneficial Ownership of Securities   —   Form 3
Filing Table of Contents

Document/Exhibit                   Description                      Pages   Size 

 1: 3           Form 3 for Page Dated 6/28/04 -- rrd46291.xml/2.2   HTML      6K 
 2: EX-24.      Power of Attorney                                   HTML      5K 


3   —   Form 3 for Page Dated 6/28/04 — rrd46291.xml/2.2


This document is an XML File that may be rendered in various formats:

Form 3  –  Plain Text  –  EDGAR System  –  SEC Website  –  XML Listing  –  <?xml?> File
 

 
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
OMB APPROVAL
OMB Number: 3235-0104
Estimated average burden
hours per response: 0.5
1. Name and Address of Reporting Person*
Page Lawrence

(Last) (First) (Middle)
C/O GOOGLE INC.
1600 AMPHITHEATRE PARKWAY

(Street)
MOUNTAIN VIEW CA 94043

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
6/28/04
3. Issuer Name and Ticker or Trading Symbol
Google Inc. [ NONE ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director X 10% Owner
X Officer (give title below)  Other (specify below)
Pres, Products, Asst. Secty
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
Series A Preferred Stock 6/28/04 (1) 6/28/04 (1) Class B Common Stock 435,200 0.0625 D 
Class B Common Stock (2) 6/28/04 (2) 6/28/04 (2) Class A Common Stock 36,658,500 0.00 (2) D 
Class B Common Stock (2) 6/28/04 (2) 6/28/04 (2) Class A Common Stock 1,500,000 0.00 (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.

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