SEC Form 3
FORM 3 | UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES 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*
(Street)
| 2. Date of Event Requiring Statement (Month/Day/Year) 05/05/2015 | 3. Issuer Name and Ticker or Trading Symbol HTG MOLECULAR DIAGNOSTICS, INC [ HTGM ] | |||||||||||||
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
| 5. If Amendment, Date of Original Filed (Month/Day/Year) | ||||||||||||||
6. Individual or Joint/Group Filing (Check Applicable Line)
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Table I - Non-Derivative Securities Beneficially Owned | |||
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1. Title of Security (Instr. 4) | 2. Amount of Securities Beneficially Owned (Instr. 4) | 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 4. Nature of Indirect Beneficial Ownership (Instr. 5) |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
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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: 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 E Convertible Preferred Stock Warrant (right to buy) | 01/14/2015 | 01/14/2022 | Series E Convertible Preferred Stock | 861,751(1) | 0.2189(1) | D | |
Series E Convertible Preferred Stock Warrant (right to buy) | 01/14/2015 | 01/14/2022 | Series E Convertible Preferred Stock | 410,454(1) | 0.2189(1) | I | By FSV II-B, L.P. |
Series E Convertible Preferred Stock Warrant (right to buy) | 01/14/2015 | 01/14/2022 | Series E Convertible Preferred Stock | 86,783(1) | 0.2189(1) | I | By FSV II, L.P. |
Series D Convertible Preferred Stock | (2) | (2) | Common Stock | 156,453(3) | 0.00(2) | D | |
Series D Convertible Preferred Stock | (2) | (2) | Common Stock | 74,519(3) | 0.00(2) | I | By FSV II-B, L.P. |
Series D Convertible Preferred Stock | (2) | (2) | Common Stock | 15,755(3) | 0.00(2) | I | By FSV II, L.P. |
Series E Convertible Preferred Stock | (4) | (4) | Common Stock | 35,966(3) | 0.00(4) | D | |
Series E Convertible Preferred Stock | (4) | (4) | Common Stock | 17,130(3) | 0.00(4) | I | By FSV II-B, L.P |
Series E Convertible Preferred Stock | (4) | (4) | Common Stock | 3,622(3) | 0.00(4) | I | By FSV II, L.P. |
1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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Explanation of Responses: |
1. Share numbers and exercise price do not give effect to the 1 for 107.39 reverse stock split of the Issuer's Common Stock effected on April 27, 2015, which will be effective for the Preferred Stock upon its conversion to Common Stock immediately prior to the closing of the Issuer's initial public offering. |
2. The shares of Series D Convertible Preferred Stock have no expiration date and are convertible at any time at the election of the holder without payment of further consideration. Each share of Series D Convertible Preferred Stock will automatically convert on a 1 for 107.39 basis into shares of Common Stock upon the closing of the Issuer's initial public offering. |
3. Share numbers assume or give effect to the 1 for 107.39 reverse stock split of the Issuer's Common Stock effected on April 27, 2015, which will be effective for the Preferred Stock upon its conversion to Common Stock immediately prior to the closing of the Issuer's initial public offering. |
4. The shares of Series E Convertible Preferred Stock have no expiration date and are convertible at any time at the election of the holder without payment of further consideration. Each share of Series E Convertible Preferred Stock will automatically convert on a 1 for 107.39 basis into shares of Common Stock upon the closing of the Issuer's initial public offering. |
Remarks: |
/s/ Fletcher Spaght Ventures II, L.P. By: Fletcher Spaght Associates II, L.P., its General Partner By: FSA II, LLC, its General Partner By: Linda Tufts, Managing Member | 05/05/2015 | |
/s/ FSV II, L.P.; By: Fletcher Spaght Associates II, LP, its General Partner; By: FSA II, LLC, its General Partner; By Linda Tufts, Managing Member | 05/05/2015 | |
/s/ FSV II-B, L.P.;By: Fletcher Spaght Associates II-B, LLC, its General Partner; By: FSA II, LLC, its Manager; By Linda Tufts, Managing Member | 05/05/2015 | |
** Signature of Reporting Person | Date | |
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | ||
* 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). | ||
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. | ||
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 Number. |