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) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
Series A Preferred Stock
|
Â
(3)
|
Â
(3)
|
Common Stock
|
401,927
|
$
(3)
|
I
|
See Footnotes
(1)
(4)
|
Series A Preferred Stock
|
Â
(3)
|
Â
(3)
|
Common Stock
|
555,956
|
$
(3)
|
I
|
See Footnotes
(2)
(4)
|
Series B Preferred Stock
|
Â
(3)
|
Â
(3)
|
Common Stock
|
44,364
|
$
(3)
|
I
|
See Footnotes
(1)
(4)
|
Series B Preferred Stock
|
Â
(3)
|
Â
(3)
|
Common Stock
|
61,366
|
$
(3)
|
I
|
See Footnotes
(2)
(4)
|
Convertible Promissory Notes
|
Â
(5)
|
Â
(5)
|
Common Stock
|
805,656.5
(5)
|
$
(5)
|
I
|
See Footnotes
(1)
(4)
|
Convertible Promissory Notes
|
Â
(5)
|
Â
(5)
|
Common Stock
|
1,114,382.5
(5)
|
$
(5)
|
I
|
See Footnotes
(2)
(4)
|
* |
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) |
Held of record by NGN Biomed Opportunity I GmbH & Co. Beteiligungs KG ("NGN Biomed GmbH"). |
(2) |
Held of record by NGN Biomed Opportunity I, L.P. ("NGN Biomed"). |
(3) |
The shares of Series A Preferred Stock and Series B Preferred Stock have no expiration date and are convertible at any time at the election of the holder. Every 2.374 shares of preferred stock will automatically convert into one share of common stock upon the closing of the Issuer's initial public offering. |
(4) |
The reporting person is a Managing General Partner of NGN Capital LLC, which is the general partner of the general partner of NGN BioMed and is the managing limited partner of NGN BioMed GMBH. The Reporting Person disclaims beneficial ownership with respect to these securities, except to the extent of his pecuniary interest therein. |
(5) |
Principal and accrued interest will convert upon the Issuer's initial public offering into shares of Common Stock at a conversion price equal to the lesser of (i) the public offering price of the Common Stock sold in the Issuer's initial public offering, or (ii) $18.92. Amounts shown are reported in US dollars and include interest accrued through the date hereof; additional interest will accrue prior to conversion. |