SEC FORM 3

Please wait

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^*

Tsai Chen Lung

(Last)

(First)

(Middle)

C/O CAPSOVISION, INC.

18805 COX AVENUE, SUITE 250

(Street)

SARATOGA

95070

(City)

(State)

(Zip)

2. Date of Event Requiring Statement (Month/Day/Year)
07/01/2025

3. Issuer Name and Ticker or Trading Symbol
CapsoVision, Inc [ CV ]

4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)

X	Director	10% Owner
	Officer (give title below)	Other (specify below)

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)
Common Stock	80,000⁽¹⁾	I	By trust.⁽³⁾

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)
1. Title of Derivative Security (Instr. 4)	Date Exercisable	Expiration Date	Title	Amount or Number of Shares	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)
Series B Preferred Stock	⁽²⁾	⁽²⁾	Common Stock	71,429⁽²⁾	⁽²⁾	I	By trust.⁽³⁾
Series D-1 Preferred Stock	⁽²⁾	⁽²⁾	Common Stock	55,555⁽²⁾	⁽²⁾	I	By trust.⁽³⁾
Series E Preferred Stock	⁽²⁾	⁽²⁾	Common Stock	86,956⁽²⁾	⁽²⁾	I	By trust.⁽³⁾
Series H Preferred Stock	⁽²⁾	⁽²⁾	Common Stock	90,534⁽²⁾	⁽²⁾	I	By trust.⁽³⁾

Explanation of Responses:

1. Does not reflect a one-for-3.33 reverse stock split, to be effective immediately prior to the closing to the Issuer's initial public offering.

2. Each share of Series B preferred stock, Series D-1 preferred stock, Series E preferred stock and Series H preferred stock (the "Preferred Stock") is convertible on a one-to-one basis into the underlying shares of common stock at the holder's election and has no expiration date. The Preferred Stock will automatically convert into common stock upon the closing of the Issuer's initial public offering. The number of underlying shares of common stock reported in Column 3 does not reflect a one-for-3.33 reverse stock split, to be effective immediately prior to the closing to the Issuer's initial public offering.

3. The securities are held by The Tsai Family Trust, for which the Reporting Person, together with his wife, are trustees.

Remarks:

Exhibit 24 - Power of Attorney

	/s/ Tai Vivatvaraphol, Attorney-in-Fact for Chen Lung Tsai	07/01/2025
	** 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.