3: Initial statement of beneficial ownership of securities
Published on October 14, 2015
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549INITIAL 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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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | SEC 1473 (7-02) | ||
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 control number. |
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 of Derivative Security: Direct (D) or Indirect (I) (Instr. 5) |
6. Nature of Indirect Beneficial Ownership (Instr. 5) |
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Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Series B Convertible Preferred Stock | (1) | (1) | Common Stock | 595,436 (2) | $ (1) | D (3) |
Reporting Owners
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Apple Tree Partners IV, L.P. 230 PARK AVENUE, SUITE 2800 NEW YORK, NY 10169 |
X | X | ||
ATP III GP, Ltd. 230 PARK AVENUE, SUITE 2800 NEW YORK, NY 10169 |
X | X | ||
Harrison Seth Loring 230 PARK AVENUE, SUITE 2800 NEW YORK, NY 10169 |
X | X |
Signatures
By Seth L. Harrison, Director of ATP III GP, Ltd, general partner of Apple Tree Partners IV, L.P. /s/ Seth L. Harrison | 10/14/2015 | |
**Signature of Reporting Person | Date | |
By Seth L. Harrison, Director of ATP III GP, Ltd. /s/ Seth L. Harrison | 10/14/2015 | |
**Signature of Reporting Person | Date | |
/s/ Seth L. Harrison | 10/14/2015 | |
**Signature of Reporting Person | Date |
Explanation of Responses:
* | 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). |
(1) | The shares of Series B Convertible Preferred Stock (the "Series B Shares") will convert automatically into Common Stock, on a 1-for-0.03571 basis, immediately prior to the closing of the Issuer's initial public offering, and have no expiration date. |
(2) | Reflects the conversion of the Series B Shares into shares of Common Stock. |
(3) | These shares are held by Apple Tree Partners IV, L.P. ("ATP IV"). ATP III GP, Ltd. (the "GP") is the sole general partner of ATP IV. Dr. Seth L. Harrison is the sole director of the GP. Dr. Seth L. Harrison disclaims beneficial ownership of the shares except to the extent of his pecuniary interest therein. |