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 C-2 Convertible Preferred Stock
|
Â
(1)
|
Â
(2)
|
Common Stock
|
341,194
|
$
(1)
|
I
|
By Burrill Life Sciences Capital Fund, L.P.
(3)
|
Series C-3 Convertible Preferred Stock
|
Â
(1)
|
Â
(2)
|
Common Stock
|
427,601
|
$
(1)
|
I
|
By Burrill Life Sciences Capital Fund, L.P.
(3)
|
Series C-2 Convertible Preferred Stock
|
Â
(1)
|
Â
(2)
|
Common Stock
|
28,377
|
$
(1)
|
I
|
By Burrill Indiana Life Sciences Capital Fund, L.P.
(4)
|
Series C-3 Convertible Preferred Stock
|
Â
(1)
|
Â
(2)
|
Common Stock
|
35,563
|
$
(1)
|
I
|
By Burrill Indiana Life Sciences Capital Fund, L.P.
(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) |
The reported securities are convertible at any time at the option of the reporting person, but automatically convert into shares of Common Stock on a 1-for-1 basis immediately prior to the closing of the Issuer's initial public offering. |
(2) |
Not applicable. |
(3) |
Ann Hanham is a managing member of Burrill & Company (Life Science GP), LLC which has the ultimate voting and investment power over shares held of record by Burrill Life Sciences Capital Fund, L.P., and she may be deemed to have voting and investment power over shares held of record by Burrill Life Sciences Capital Fund, L.P. Ms. Hanham disclaims beneficial ownership of the shares directly held by the entities affiliated with Burrill & Company except to the extent of her individual pecuniary interest therein. |
(4) |
Ann Hanham is a managing member of Burrill & Company (Indiana GP), LLC which has the ultimate voting and investment power over shares held of record by Burrill Indiana Life Sciences Capital Fund, L.P., and she may be deemed to have voting and investment power over shares held of record by Burrill Indiana Life Sciences Capital Fund, L.P. Ms. Hanham disclaims beneficial ownership of the shares directly held by the entities affiliated with Burrill & Company except to the extent of her individual pecuniary interest therein. |