UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549INITIAL STATEMENT OF 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. | SEC 1473 (7-02) | ||
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. |
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) |
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Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Series A Preferred Stock | Â (2) | Â (2) | Common Stock | 18,272 | $ 0 | I | By the Bauer Family 1995 Trust (1) |
Employee Stock Option (right to buy) | Â (3) | 10/03/2021 | Common Stock | 110,434 | $ 0.986 | D | Â |
Employee Stock Option (right to buy) | Â (4) | 02/08/2022 | Common Stock | 32,758 | $ 0.986 | D | Â |
Employee Stock Option (right to buy) | Â (4) | 01/03/2023 | Common Stock | 146,234 | $ 1.218 | D | Â |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
BAUER EUGENE A C/O DERMIRA, INC. 2055 WOODSIDE ROAD REDWOOD CITY, CA 94061 |
 X |  |  Chief Medical Officer |  |
/s/ Christine Ring, by power of attorney | 10/02/2014 | |
**Signature of Reporting Person | Date |
* | 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 Reporting Person is a Co-Trustee. |
(2) | Each share of Preferred Stock will be automatically converted into one (1) share of Common Stock, for no additional consideration, immediately prior to the consummation of the Issuer's initial public offering, and has no expiration date. |
(3) | The stock option vests and becomes exercisable in 48 equal monthly installments beginning one month after the vesting commencement date, until such time as the option is 100% vested, subject to the continuing employment of the Reporting Person on each vesting date. |
(4) | The stock option vests and becomes exercisable as to 25% of the shares subject to the option on the one-year anniversary of the vesting commencement date, and thereafter vests as to 1/48th of the shares in equal monthly installments, subject to the continuing employment of the Reporting Person on each vesting date. |