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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 Preferred Stock | (1) | 02/04/2015 | C | 1,000,000 | (1) | (1) | Common Stock | 1,000,000 | $ 0 | 0 | D | ||||
Series B Preferred Stock | (2) | 02/04/2015 | C | 2,795,031 | (2) | (2) | Common Stock | 2,795,031 | $ 0 | 0 | D | ||||
Accrued Preferred Stock Dividends | (3) | 02/04/2015 | C | 61,552 | (3) | (3) | Common Stock | 61,552 | $ 0 | 0 | D |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Children's Hospital of Philadelphia Foundation 3737 MARKET STREET SUITE 1300 PHILADELPHIA, PA 19104 |
X |
Jeffrey D. Kahn, Attorney-In-Fact for The Children's Hospital of Philadelphia Foundation | 02/04/2015 | |
**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) | Shares of Series A Preferred Stock automatically converted into shares of the Common Stock on a one-for-one basis without payment of further consideration upon the closing of the Issuer's initial public offering on February 4, 2015. |
(2) | Shares of Series B Preferred Stock automatically converted into shares of the Common Stock on a one-for-one basis without payment of further consideration upon the closing of the Issuer's initial public offering on February 4, 2015. |
(3) | Paid-in-kind dividends declared and paid on the Series A Preferred Stock and Series B Preferred Stock automatically converted into shares of Common Stock on a one-for-one basis without payment of further consideration upon the closing of the issuer's initial public offering on February 4, 2015. |