SEC FORM 4

SEC FORM 4 SEC Form 4

FORM 4

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

STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

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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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^*

AKKARAJU SRINIVAS

(Last)

(First)

(Middle)

628 MIDDLEFIELD ROAD

(Street)

PALO ALTO

94301

(City)

(State)

(Zip)

2. Issuer Name and Ticker or Trading Symbol
Jiya Acquisition Corp. [ JYAC ]

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

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

3. Date of Earliest Transaction (Month/Day/Year)
09/23/2021

4. If Amendment, Date of Original Filed (Month/Day/Year)

6. Individual or Joint/Group Filing (Check Applicable Line)

	Form filed by One Reporting Person
X	Form filed by More than One Reporting Person

Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security (Instr. 3)	2. Transaction Date (Month/Day/Year)	2A. Deemed Execution Date, if any (Month/Day/Year)	3. Transaction Code (Instr. 8)		4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5)			5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4)	6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)	7. Nature of Indirect Beneficial Ownership (Instr. 4)
1. Title of Security (Instr. 3)	2. Transaction Date (Month/Day/Year)	2A. Deemed Execution Date, if any (Month/Day/Year)	Code	V	Amount	(A) or (D)	Price		6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)	7. Nature of Indirect Beneficial Ownership (Instr. 4)

Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 3)	2. Conversion or Exercise Price of Derivative Security	3. Transaction Date (Month/Day/Year)	3A. Deemed Execution Date, if any (Month/Day/Year)	4. Transaction Code (Instr. 8)		5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5)		6. Date Exercisable and Expiration Date (Month/Day/Year)		7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4)		8. Price of Derivative Security (Instr. 5)	9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4)	10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)	11. Nature of Indirect Beneficial Ownership (Instr. 4)
1. Title of Derivative Security (Instr. 3)	2. Conversion or Exercise Price of Derivative Security	3. Transaction Date (Month/Day/Year)	3A. Deemed Execution Date, if any (Month/Day/Year)	Code	V	(A)	(D)	Date Exercisable	Expiration Date	Title	Amount or Number of Shares	8. Price of Derivative Security (Instr. 5)		10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)	11. Nature of Indirect Beneficial Ownership (Instr. 4)
Class B Common Stock⁽¹⁾	⁽¹⁾	09/23/2021		J⁽²⁾		30,000⁽²⁾		⁽¹⁾	⁽¹⁾	Class A Common Stock	30,000	⁽¹⁾⁽²⁾	2,437,447⁽¹⁾⁽³⁾	I	See Footnotes⁽³⁾⁽⁴⁾
Class B Common Stock⁽¹⁾	⁽¹⁾	09/23/2021		J⁽⁵⁾			30,000⁽⁵⁾	⁽¹⁾	⁽¹⁾	Class A Common Stock	30,000	⁽¹⁾⁽⁵⁾	2,407,447⁽¹⁾⁽³⁾	I	See Footnotes⁽³⁾⁽⁴⁾

1. Name and Address of Reporting Person^*

AKKARAJU SRINIVAS

(Last)

(First)

(Middle)

628 MIDDLEFIELD ROAD

(Street)

PALO ALTO

94301

(City)

(State)

(Zip)

1. Name and Address of Reporting Person^*

Jiya Holding Co LLC

(Last)

(First)

(Middle)

628 MIDDLEFIELD ROAD

(Street)

PALO ALTO

94301

(City)

(State)

(Zip)

Explanation of Responses:

1. The shares of Class B Common Stock of the Issuer ("Class B Shares") will automatically convert into shares of Class A Common Stock of the Issuer ("Class A Shares") on a one-for-one basis (subject to certain adjustments for stock splits, stock dividends, reorganizations, recapitalizations and similar transactions) concurrently with or immediately following the consummation of the Issuer's initial business combination, as described in the section entitled "Description of Securities" in the Issuer's Registration Statement on Form S-1 (File No. 333-249808) filed with the Securities and Exchange Commission on November 16, 2020. The Class B Shares have no expiration date.

2. Reflects the forfeiture of Class B Shares held by a director of the Board of Directors of the Issuer ("Issuer Board") upon such director's resignation from the Issuer Board. As a result, these Class B Shares were automatically returned to Jiya Holding Company LLC ("Jiya Holdco") for no consideration ($0).

3. Reflects the Class B Shares held by Jiya Holdco. This amount does not reflect the 30,000 Class B shares directly held by Dr. Srinivas Akkaraju M.D., Ph.D.

4. Jiya HoldCo is wholly owned by Samsara BioCapital, L.P. ("Samsara LP"). Dr. Akkaraju has voting and dispositive control over the reported securities held by Jiya Holdco via Dr. Akkaraju's control of Samsara LP's general partner, Samsara BioCapital GP, LLC. Each of the Reporting Persons disclaims beneficial ownership of the reported securities except to the extent of his or its pecuniary interest therein.

5. Reflects the transfer of 30,000 Class B Shares from Jiya Holdco for no consideration ($0) to a director appointed to the Issuer Board in respect of their service on the Issuer Board. These Class B Shares are subject to forfeiture if the director is removed from office as a director or voluntarily resigns from their position as a member of the Issuer Board at any time before the consummation of the Issuer's initial business combination. Upon any such forfeiture, the Class B Shares will be automatically returned to Jiya Holdco for no consideration ($0).

	By: /s/ Srinivas Akkaraju, By: Richard Van Doren, attorney-in-fact	09/27/2021
	By: /s/ Jiya Holding Company LLC, By: Samsara BioCapital, L.P., its sole member, By: Samsara BioCapital GP, LLC, its General Partner, By: Richard Van Doren, its Chief Financial Officer	09/27/2021
	** 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 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).
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SEC Form 4 filed by Akkaraju Srinivas