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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 | $ 0 (1) | 10/08/2014 | C | 1,708,040 | (1) | (3) | Common Stock | 1,708,040 | $ 0 (1) | 0 | I | See footnote (2) | |||
Series B Preferred Stock | $ 0 (1) | 10/08/2014 | C | 469,878 | (1) | (3) | Common Stock | 469,878 | $ 0 (1) | 0 | I | See footnote (2) | |||
Series C Preferred Stock | $ 0 (1) | 10/08/2014 | C | 272,955 | (1) | (3) | Common Stock | 272,955 | $ 0 (1) | 0 | I | See footnote (2) |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Hutton Wende S C/O DERMIRA, INC. 2055 WOODSIDE ROAD REDWOOD CITY, CA 94061 |
X |
/s/ Jaime Slocum, Attorney-in-fact | 10/08/2014 | |
**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) | In connection with the consummation of the Issuer's initial public offering on October 8, 2014, each share of Preferred Stock automatically converted into one (1) share of Common Stock for no additional consideration. All shares of Common Stock issued upon conversion were aggregated. |
(2) | Shares held directly by Canaan VIII L.P. (the "Canaan Fund"). Canaan Partners VIII LLC ("Canaan VIII" and together with the Canaan Fund, the "Canaan Entities") is the sole general partner of the Canaan Fund. Investment and voting decisions with respect to the shares held by the Canaan Fund are made by the managers of Canaan VIII, collectively, and no manager of Canaan VIII has beneficial ownership of any shares held by Canaan VIII L.P. Wende Hutton, a manager and member of Canaan VIII, serves as the representative of the Canaan Entities on the Issuer's board of directors. Ms. Hutton disclaims beneficial ownership in the securities held by the Canaan Entities, except to the extent of her pecuniary interest, if any, in such securities by virtue of the limited liability company interests she owns in Canaan VIII. |
(3) | None. |