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
|
| OMB APPROVAL |
| OMB Number: |
3235-0104 |
| Estimated average burden |
| hours per response: |
0.5 |
|
|
1. Name and Address of Reporting Person*
| C/O SYMBOTIC INC., 200 RESEARCH DRIVE |
|
(Street)
|
2. Date of Event Requiring Statement
(Month/Day/Year)
06/20/2022
|
3. Issuer Name and Ticker or Trading Symbol
Symbotic Inc.
[ SYM ]
|
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
|
Director |
|
10% Owner |
| X |
Officer (give title below) |
|
Other (specify below) |
|
Vice President & Controller
|
|
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 |
| Explanation of Responses: |
| Remarks: |
|
| No securities are beneficially owned. |
|
/s/ Corey Dufresne, Attorney-in-Fact |
06/28/2022 |
|
** 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. |
POWER OF ATTORNEY
With respect to holdings of and transactions in securities issued
by Symbotic Inc. (the "Company"), the undersigned hereby constitutes and
appoints the persons named on Schedule 1 attached hereto, as may be amended
from time to time (the "Attorneys-in-Fact"), including an Attorney-in-Fact
acting or signing singly, with full power of substitution and resubstitution,
to act as the undersigned's true and lawful attorney-in-fact to:
1. prepare, execute in the undersigned's name and on the
undersigned's behalf, and submit to the U.S. Securities and Exchange Commission
(the "SEC") a Form ID, including amendments thereto, and any other documents
necessary or appropriate to obtain and/or regenerate codes and passwords
enabling the undersigned to make electronic filings with the SEC of reports
required by Section 16 of the Securities Exchange Act of 1934, as amended, and
the rules and regulations promulgated thereunder;
2. execute for and on behalf of the undersigned, Forms 3, 4 and
5 in accordance with Section 16 of the Securities Exchange Act of 1934, as
amended, and the rules and regulations promulgated thereunder;
3. do and perform any and all acts for and on behalf of the
undersigned that may be necessary or desirable to complete and execute any such
Form 3, 4 or 5, complete and execute any amendment or amendments thereto, and
timely file such form with the SEC and any stock exchange or similar authority;
and
4. take any other action of any type whatsoever in connection
with the foregoing that, in the opinion of such Attorneys-in-Fact, may be of
benefit to, in the best interest of or legally required by the undersigned, it
being understood that the documents executed by such Attorneys-in-Fact on
behalf of the undersigned pursuant to this power of attorney shall be in such
form and shall contain such terms and conditions as such Attorneys-in-Fact may
approve in such Attorneys-in-Fact's discretion.
The undersigned hereby grants to each such Attorneys-in-Fact full
power and authority to do and perform any and every act and thing whatsoever
requisite, 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 and resubstitution or revocation, hereby ratifying and confirming
all that such Attorneys-in-Fact, or such Attorneys-in-Fact substitute or
substitutes, shall lawfully do or cause to be done by virtue of this power of
attorney and the rights and powers herein granted.
The undersigned acknowledges that the Attorneys-in-Fact, in
serving in such capacity at the request of the undersigned, are not assuming,
nor is any Company assuming, any of the undersigned's responsibilities to
comply with Section 16 of the Securities Exchange Act of 1934, as amended.
This power of attorney shall remain in full force and effect until
the undersigned is no longer required to file Forms 3, 4 and 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 the Attorneys-in-Fact.
IN WITNESS WHEREOF, the undersigned has caused this power of
attorney to be executed as of June 22, 2022.
By: /s/ Santhosh Daniel
-------------------------------
(Sign Name)
Santhosh Daniel
-------------------------------
(Print Name)
Schedule 1
ATTORNEYS-IN-FACT
Corey Dufresne
Kristen Galbreath
Sullivan & Cromwell LLP
