Statement of Changes in Beneficial Ownership (4)
24 Janeiro 2020 - 6:04PM
Edgar (US Regulatory)
FORM 4
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0287
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0.5
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Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person
*
3x5 Partners, LLC |
2. Issuer Name and Ticker or Trading Symbol
VAPOTHERM INC
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VAPO
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
_____ Director __X__ 10% Owner _____ Officer (give title below) _____ Other (specify below)
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(Last)
(First)
(Middle)
2540 NE MARTIN LUTHER KING JR. BLVD. |
3. Date of Earliest Transaction
(MM/DD/YYYY)
11/16/2018 |
(Street)
PORTLAND, OR 97212
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
_X
_ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security (Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code (Instr. 8)
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4. Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)
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7. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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Amount
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(A) or (D)
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Price
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Common Stock | 11/16/2018 | | C | | 2042595 | A | (1) | 2042595 | I | By Vapotherm Investors, LLC (3) |
Common Stock | 11/16/2018 | | C | | 208752 | A | (2) | 2251347 | I | By Vapotherm Investors, LLC (3) |
Common Stock | 11/16/2018 | | C | | 42857 | A | (1) | 2294204 | I | By Vapotherm Investors, LLC (3) |
Common Stock | 11/16/2018 | | C | | 1049958 | A | (1) | 1049958 | I | By 3x5 Special Opportunity Fund, L.P. (4) |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security (Instr. 3) | 2. Conversion or Exercise Price of Derivative Security | 3. Trans. Date | 3A. Deemed Execution Date, if any | 4. Trans. 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 | 7. Title and Amount of Securities Underlying Derivative Security (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) |
Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Series A Convertible Preferred Stock | (1) | 11/16/2018 | | C | | | 227600 | (1) | (1) | Common Stock | 227600 | $0.00 | 0 | I | By Vapotherm Investors, LLC (3) |
Series B Convertible Preferred Stock | (1) | 11/16/2018 | | C | | | 75700 | (1) | (1) | Common Stock | 75700 | $0.00 | 0 | I | By Vapotherm Investors, LLC (3) |
Series C Convertible Preferred Stock | (1) | 11/16/2018 | | C | | | 849239 | (1) | (1) | Common Stock | 849239 | $0.00 | 0 | I | By Vapotherm Investors, LLC (3) |
Series D Convertible Preferred Stock | (1) | 11/16/2018 | | C | | | 890056 | (1) | (1) | Common Stock | 890056 | $0.00 | 0 | I | By Vapotherm Investors, LLC (3) |
Series D-1 Convertible Preferred Stock | (2) | 11/16/2018 | | C | | | 208752 | (2) | (2) | Common Stock | 208752 | $0.00 | 0 | I | By Vapotherm Investors, LLC (3) |
Warrant to purchase Series A Convertible Preferred Stock | (1) | 11/16/2018 | | C | | | 42857 | (1) | (1) | Common Stock | 42857 | $0.00 | 0 | I | By Vapotherm Investors, LLC (3) |
Series A Convertible Preferred Stock | (1) | 11/16/2018 | | C | | | 500000 | (1) | (1) | Common Stock | 500000 | $0.00 | 0 | I | By 3x5 Special Opportunity Fund, L.P. (4) |
Series B Convertible Preferred Stock | (1) | 11/16/2018 | | C | | | 285714 | (1) | (1) | Common Stock | 285714 | $0.00 | 0 | I | By 3x5 Special Opportunity Fund, L.P. (4) |
Series C Convertible Preferred Stock | (1) | 11/16/2018 | | C | | | 264244 | (1) | (1) | Common Stock | 264244 | $0.00 | 0 | I | By 3x5 Special Opportunity Fund, L.P. (4) |
Explanation of Responses: |
(1) | Upon closing of the Issuer's initial public offering, each Warrant and each share of Series A Convertible Preferred Stock, Series B Convertible Preferred Stock, Series C Convertible Preferred Stock and Series D Convertible Preferred Stock automatically converted into one share of Common Stock without payment or further consideration. There was no expiration date for the Series A Convertible Preferred Stock, the Series B Convertible Preferred Stock, the Series C Convertible Preferred Stock or the Series D Convertible Preferred Stock. |
(2) | Upon closing of the Issuer's initial public offering, each share of Series D-1 Convertible Preferred Stock automatically converted into 1.137 shares of Common Stock without payment or further consideration. There was no expiration date for the Series D-1 Convertible Preferred Stock. |
(3) | The Reporting Person is the managing member of Vapotherm Investors, LLC, the direct beneficial owner of these securities. The Reporting Person disclaims beneficial ownership, within the meaning of Section 16 of the Securities Exchange Act of 1934, as amended, or otherwise, of such securities except to the extent of its pecuniary interest therein. |
(4) | The Reporting Person is a member of 3x5 Special Opportunity Partners, LLC. 3x5 Special Opportunity Partners, LLC is the general partner of 3x5 Special Opportunity Fund, L.P., the direct beneficial owner of these securities. The Reporting Person disclaims beneficial ownership, within the meaning of Section 16 of the Securities Exchange Act of 1934, as amended, or otherwise, of such securities except to the extent of its pecuniary interest therein. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
3x5 Partners, LLC 2540 NE MARTIN LUTHER KING JR. BLVD. PORTLAND, OR 97212 |
| X |
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Signatures
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/s/ Anthony Ten Haagen, as Attorney-In-Fact | | 1/24/2020 |
**Signature of Reporting Person | Date |
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