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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 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. | |||
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. | SEC 1474 (9-02) |
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 Underlying Securities (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 of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
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Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||||||
Series A Convertible Preferred Stock | (1) | 08/02/2011 | C | 401,927 | (5) | (5) | Common Stock | 401,927 | $ 0 | 0 | I | See FN (2) | |||
Series A Convertible Preferred Stock | (1) | 08/02/2011 | C | 555,956 | (1) | (1) | Common Stock | 555,956 | $ 0 | 0 | I | See FN (4) | |||
Series B Convertible Preferred Stock | (1) | 08/02/2011 | C | 44,364 | (5) | (5) | Common Stock | 44,364 | $ 0 | 0 | I | See FN (2) | |||
Series B Convertible Preferred Stock | (1) | 08/02/2011 | C | 61,366 | (1) | (1) | Common Stock | 61,366 | $ 0 | 0 | I | See FN (4) | |||
Convertible Promissory Notes | $ 9 | 08/02/2011 | C | $ 806,879.04 | (6) | (6) | Common Stock | 89,652 | $ 0 | 0 | I | See FN (2) | |||
Convertible Promissory Notes | $ 9 | 08/02/2011 | C | $ 1,116,079.76 | (6) | (6) | Common Stock | 124,007 | $ 0 | 0 | I | See FN (4) |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Birner Hubert C/O HORIZON PHARMA, INC. 1033 SKOKIE BLVD., SUITE 355 NORTHBROOK, IL 60062 |
X |
/s/ Robert J. De Vaere, Attorney-in-Fact | 08/04/2011 | |
**Signature of Reporting Person | Date |
* | 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). |
(1) | Automatic conversion, in connection with the Issuer's initial public offering, of preferred stock into shares of common stock. Every 2.374 shares of preferred stock converted into one share of common stock upon the closing of the Issuer's initial public offering. |
(2) | The securities are held of record by TVM Life Science Ventures VI, L.P. ("TVM VI"). The Reporting Person disclaims beneficial ownership of these shares, except to the extent of his pecuniary interest therein. |
(3) | Represents shares acquired upon conversion, in connection with the Issuer's initial public offering, of convertible promissory notes. |
(4) | The securities are held of record by TVM Life Science Ventures VI GmbH & Co. KG ("TVM VI GmbH"). The Reporting Person disclaims beneficial ownership of these shares, except to the extent of his pecuniary interest therein |
(5) | These securities are preferred stock of the Issuer and did not have an expiration date. Prior to the Issuer's initial public offering of common stock, the securities were convertible at any time at the election of the holder. The securities automatically converted into shares of common stock upon the closing of the issuer's initial public offering of common stock. |
(6) | Principal and accrued interest converted upon the Issuer's initial public offering of common stock, into shares of common stock. |