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 B Convertible Preferred Stock
|
Â
(1)
|
Â
(1)
|
Common Stock
|
988,446
(1)
|
$
0
(1)
|
I
|
Frazier Healthcare IV, L.P.
(2)
|
Series B Convertible Preferred Stock
|
Â
(1)
|
Â
(1)
|
Common Stock
|
5,016
(1)
|
$
0
(1)
|
I
|
Frazier Affiliates IV, L.P.
(2)
|
Series C Convertible Preferred Stock
|
Â
(1)
|
Â
(1)
|
Common Stock
|
1,011,088
(1)
|
$
0
(1)
|
I
|
Frazier Healthcare IV, L.P.
(2)
|
Series C Convertible Preferred Stock
|
Â
(1)
|
Â
(1)
|
Common Stock
|
5,132
(1)
|
$
0
(1)
|
I
|
Frazier Affiliates, IV, L.P.
(2)
|
Series D Convertible Preferred Stock
|
Â
(1)
|
Â
(1)
|
Common Stock
|
572,310
(1)
|
$
0
(1)
|
I
|
Frazier Healthcare IV, L.P.
(2)
|
Series D Convertible Preferred Stock
|
Â
(1)
|
Â
(1)
|
Common Stock
|
2,904
(1)
|
$
0
(1)
|
I
|
Frazier Affiliates IV, L.P.
(2)
|
Series B Convertible Preferred Stock Warrant (right to buy)
|
Â
(3)
|
Â
(3)
|
Series B Convertible Preferred Stock
|
15,042
|
$
6.375
|
I
|
Frazier Healthcare IV, L.P.
(2)
|
Series B Convertible Preferred Stock Warrant (right to buy)
|
Â
(3)
|
Â
(3)
|
Series B Convertible Preferred Stock
|
76
|
$
6.375
|
I
|
Frazier Affiliates IV, L.P.
(2)
|
* |
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) |
Each share is convertible and will automatically convert on a 1-for-1 basis into the Issuer's common stock upon the closing of the Issuer's initial public offering of common stock pursuant to an effecive registration statement filed with the U.S. Securities and Exchange Commission. These shares have no expiration date. |
(2) |
The securities are owned directly by the entity listed. The reporting person is a limited partner of FHM IV, LP, the general partner of Frazier Healthcare IV, LP and Frazier Affiliates IV, LP. Voting and investment power over such shares is exercised by FHM IV, LLC in its role as the general partner of FHM IV, LP. The reporting person disclaims beneficial ownership of these shares except to the extent of his proportionate pecuniary interest therein, and the inclusion of these shares in this report shall not be deemed an admission of beneficial ownership of the shares for purposes of Section 16 or for any other purpose. |
(3) |
The warrants to purchase Series B convertible preferred stock will automatically be exercised for cash immediately prior to the closing of the Issuer's initial public offering. |