# EDGAR Filing Document

**Accession Number:** 0001378325
**File Stem:** 0001009165-25-000003
**Filing Date:** 2025-7
**Character Count:** 7110
**Document Hash:** 2e049c0f19cf1ec425c322ac68f23203
**Contains OCR:** False
**Source Format:** 

## Filing Content

## Filing Summary
**0001009165-25-000003.hdr.sgml**: 20250702

**ACCESSION NUMBER**: 0001009165-25-000003

**CONFORMED SUBMISSION TYPE**: 3

**PUBLIC DOCUMENT COUNT**: 1

**CONFORMED PERIOD OF REPORT**: 20250701

**FILED AS OF DATE**: 20250702

**DATE AS OF CHANGE**: 20250702

**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** HARARI ELIYAHOU ET AL
- **CENTRAL INDEX KEY:** 0001009165

**ORGANIZATION NAME:**

**FILING VALUES:**
- **FORM TYPE:** 3
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-42705
- **FILM NUMBER:** 251103417

**MAIL ADDRESS:**
- **STREET 1:** 140 CASPIAN COURT
- **STREET 2:** C/O SANDISK CORP
- **CITY:** SUNNYVALE
- **STATE:** CA
- **ZIP:** 94089
**ISSUER**: 

**COMPANY DATA:**
- **COMPANY CONFORMED NAME:** CapsoVision, Inc
- **CENTRAL INDEX KEY:** 0001378325
- **STANDARD INDUSTRIAL CLASSIFICATION:** ELECTROMEDICAL & ELECTROTHERAPEUTIC APPARATUS [3845]
- **ORGANIZATION NAME:** 08 Industrial Applications and Services
- **EIN:** 203369494
- **STATE OF INCORPORATION:** DE
- **FISCAL YEAR END:** 1231

**BUSINESS ADDRESS:**
- **STREET 1:** 18805 COX AVENUE SUITE 250
- **CITY:** SARATOGA
- **STATE:** CA
- **ZIP:** 95070
- **BUSINESS PHONE:** (408) 370-4790

**MAIL ADDRESS:**
- **STREET 1:** 18805 COX AVENUE SUITE 250
- **CITY:** SARATOGA
- **STATE:** CA
- **ZIP:** 95070

**FORMER COMPANY:**
- **FORMER CONFORMED NAME:** Capso Vision Inc
- **DATE OF NAME CHANGE:** 20061016

### UNITED STATES SECURITIES AND EXCHANGE COMMISSION
**Washington, D.C. 20549**

## FORM 3

### INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES

[ ] Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).

---

| | | |
|:---|:---|:---|
| **1. Name and Address of Reporting Person**<sup>*</sup><br>HARARI ELIYAHOU ET AL<br><sub>(Last) (First) (Middle)</sub><br>225 CHARCOT<br><sub>(Street)</sub><br>SAN JOSE, CA 95131<br><sub>(City) (State) (Zip)</sub> | **3. Issuer Name and Ticker or Trading Symbol**<br>CapsoVision, Inc [ CV ] | **5. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  |
| **2. Date of Event Requiring Statement (Month/Day/Year)**<br>2025-07-01 | **4. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[ ] Director   [X] 10% Owner<br>[ ] Officer (give title below)   [ ] Other (specify below)<br>_ _ | **6. Individual or Joint/Group Filing (Check Applicable Line)**<br>[X] Form filed by One Reporting Person<br>[ ] Form filed by More than One Reporting Person |

---

## Table I - Non-Derivative Securities Beneficially Owned

---

|  |  |  |  |
| --- | --- | --- | --- |
| 1. Title of Security | 2. Amount of Securities Beneficially Owned | 3. Ownership Form | 4. Nature of Indirect Beneficial Ownership |
| Common Stock | 280000<sup>(1)</sup> | D |  |

---

## Table II - Derivative Securities Beneficially Owned

---

|  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- |
| 1. Title of Derivative Security | 2. Date Exercisable and Expiration Date (Month/Day/Year) | 2. Date Exercisable and Expiration Date (Month/Day/Year) | 3. Title and Amount of Underlying Securities | 3. Title and Amount of Underlying Securities | 4. Conversion or Exercise Price | 5. Ownership Form | 6. Nature of Indirect Beneficial Ownership |
| 1. Title of Derivative Security | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | 4. Conversion or Exercise Price | 5. Ownership Form | 6. Nature of Indirect Beneficial Ownership |
| Series D-1 Preferred Stock | <sup>(2)</sup> | <sup>(2)</sup> | Common Stock | 222222<sup>(2)</sup> | <sup>(2)</sup> | I | By trust.<sup>(3)</sup> |
| Series D-2 Preferred Stock | <sup>(2)</sup> | <sup>(2)</sup> | Common Stock | 934588<sup>(2)</sup> | <sup>(2)</sup> | I | By trust.<sup>(3)</sup> |
| Series E Preferred Stock | <sup>(2)</sup> | <sup>(2)</sup> | Common Stock | 434782<sup>(2)</sup> | <sup>(2)</sup> | I | By trust.<sup>(3)</sup> |
| Series F-1 Preferred Stock | <sup>(2)</sup> | <sup>(2)</sup> | Common Stock | 434783<sup>(2)</sup> | <sup>(2)</sup> | I | By trust.<sup>(3)</sup> |
| Series F-2 Preferred Stock | <sup>(2)</sup> | <sup>(2)</sup> | Common Stock | 2000000<sup>(2)</sup> | <sup>(2)</sup> | I | By trust.<sup>(3)</sup> |
| Series G Preferred Stock | <sup>(2)</sup> | <sup>(2)</sup> | Common Stock | 740741<sup>(2)</sup> | <sup>(2)</sup> | I | By trust.<sup>(3)</sup> |
| Series G-1 Preferred Stock | <sup>(2)</sup> | <sup>(2)</sup> | Common Stock | 1206898<sup>(2)</sup> | <sup>(2)</sup> | I | By trust.<sup>(3)</sup> |
| Series H Preferred Stock | <sup>(2)</sup> | <sup>(2)</sup> | Common Stock | 4638377<sup>(2)</sup> | <sup>(2)</sup> | I | By trust.<sup>(3)</sup> |
| Series H Preferred Stock | <sup>(2)</sup> | <sup>(2)</sup> | Common Stock | 1724139<sup>(2)</sup> | <sup>(2)</sup> | I | By trust.<sup>(4)</sup> |
| Series H Preferred Stock | <sup>(2)</sup> | <sup>(2)</sup> | Common Stock | 1724139<sup>(2)</sup> | <sup>(2)</sup> | I | By trust.<sup>(5)</sup> |

---

### Footnotes:

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

(2) Each share of Series D-1 preferred stock, Series D-2 preferred stock, Series E preferred stock, Series F-1 preferred stock, Series F-2 preferred stock, Series G preferred stock, Series G-1 preferred stock and Series H preferred stock (the Preferred Stock) is convertible on a one-to-one basis into shares of common stock at the election of the holder and has no expiration date. The Preferred Stock will automatically convert into the underlying shares of common stock upon the closing of the initial public offering of the Issuer. 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 of the initial public offering of the Issuer.

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

(4) The securities are held by Harari 2010 Children Remainder Trust - MHG, for which the Reporting Person, together with his wife, are trustees.

(5) The securities are held by Harari 2010 Children Remainder Trust - DAH, for which the Reporting Person, together with his wife, are trustees.

**Signature:** /s/ Peter Bergman, Attorney-in-Fact for Eliyahou Harari  
**Date:** 2025-07-01

### Remarks:

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 4 (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.**