SEC FORM
3
SEC Form 3
| 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
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| OMB APPROVAL |
| OMB Number: |
3235-0104 |
| Estimated average burden |
| hours per response: |
0.5 |
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1. Name and Address of Reporting Person*
| C/O HEALTHEQUITY, INC. |
| 15 W. SCENIC POINTE DR., STE 100 |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
04/15/2019
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3. Issuer Name and Ticker or Trading Symbol
HEALTHEQUITY INC
[ HQY ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
|
Director |
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10% Owner |
| X |
Officer (give title below) |
|
Other (specify below) |
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EVP Chief Marketing Officer
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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)
| X |
Form filed by One Reporting Person |
|
Form filed by More than One Reporting Person |
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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)
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3. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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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)
|
|---|
| 1. Title of Derivative Security (Instr.
4)
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2. Date Exercisable and Expiration Date
(Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr.
4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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6. Nature of Indirect Beneficial Ownership (Instr.
5)
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| Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
| Explanation of Responses: |
| Remarks: |
|
| No securities are beneficially owned. |
|
/s/ Adam Hostetter |
04/18/2019 |
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** 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. |
LIMITED POWER OF ATTORNEY FOR SECTION 16 REPORTING
OBLIGATIONS
Know all by these present that the undersigned hereby
constitutes and appoints each of Delano W. Ladd, Darcy
G. Mott, and Willkie Farr & Gallagher LLP, or any of
them acting singly and with full power of
substitution, the undersigned's true and lawful
attorney-in-fact to:
1. execute for and on behalf of the
undersigned, in the undersigned's capacity as an
officer or director or both of HealthEquity, Inc. (the
"Company"), Forms 3, 4 and 5 (and any amendments
thereto) in accordance with Section 16(a) of the
Securities Exchange Act of 1934, as amended (the
"Exchange Act"), and the rules thereunder;
2. do and perform any and all acts for and on
behalf of the undersigned which may be necessary or
desirable to complete and execute any such Form 3, 4
or 5, complete and execute any amendments thereto, and
timely file such form with the U.S. Securities and
Exchange Commission (the "SEC") and any securities
exchange or similar authority, including without
limitation the filing of a Form ID or any other
documents necessary or appropriate to enable the
undersigned to file the Forms 3, 4 and 5
electronically with the SEC;
3. seek or obtain, as the undersigned's
representative and on the undersigned's behalf,
information on transactions in the Company's
securities from any third party, including brokers,
employee benefit plan administrators and trustees, and
the undersigned hereby authorizes any such person to
release any such information to each of the
undersigned's attorneys-in-fact appointed by this
Limited Power of Attorney and approves and ratifies
any such release of information; and
4. take any other action in connection with the
foregoing which, in the opinion of such attorney-in-
fact, may be of benefit to, in the best interest of,
or legally required by or for, the undersigned, it
being understood that the documents executed by such
attorney-in-fact on behalf of the undersigned pursuant
to this Limited Power of Attorney shall be in such
form and shall contain such information and disclosure
as such attorney-in-fact may approve in such attorney-
in-fact's discretion.
The undersigned hereby grants to each such attorney-
in-fact full power and authority to do and perform any
and every act and thing whatsoever required, necessary
or proper to be done in the exercise of any of the
rights and powers herein granted, as fully to all
intents and purposes as the undersigned might or could
do if personally present, with full power of
substitution or revocation, hereby ratifying and
confirming all that such attorney-in-fact, or such
attorney-in-fact's substitute or substitutes, shall
lawfully do or cause to be done by virtue of this
Limited Power of Attorney and the rights and powers
herein granted.
The undersigned acknowledges that the foregoing
attorneys-in-fact, in serving in such capacity at the
request and on the behalf of the undersigned, are not
assuming, nor is the Company assuming, any of the
undersigned's responsibilities to comply with, or any
liability for the failure to comply with, any
provision of Section 16 of the Exchange Act.
This Limited Power of Attorney revokes any earlier
Limited Power of Attorney delivered to the Company by
the undersigned relating to the matters contemplated
herein and shall remain in full force and effect until
the undersigned is no longer required to file Forms 3,
4 or 5 with respect to the undersigned's holdings of
and transactions in securities issued by the Company,
unless earlier revoked by the undersigned in a signed
writing delivered to each of the foregoing attorneys-
in-fact.
IN WITNESS WHEREOF, the undersigned has executed this
Limited Power of Attorney as of this 15th day of April,
2019.
Signed and acknowledged:
/s/ Adam Hostetter
