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) 07/19/2016 | 3. Issuer Name and Ticker or Trading Symbol Audentes Therapeutics, Inc. [ BOLD ] | |||||||||||||
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) |
Common Stock | 466,799 | D | |
Common Stock | 25,678 | I | By Amygdala Lange Trust(1) |
Common Stock | 8,558 | I | By Lange Minors?Trust(2) |
Common Stock | 73,943 | I | By Asset Management Ventures Fund, L.P.(3) |
Common Stock | 12,322 | I | By Camp Lowell, LLC(4) |
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 B Preferred Stock | (5) | (5) | Common Stock | 9,000 | (5) | D | |
Series B Preferred Stock | (5) | (5) | Common Stock | 13,400 | (5) | I | By Asset Management Ventures Fund, L.P.(3) |
Series B Preferred Stock | (5) | (5) | Common Stock | 2,233 | (5) | I | By Camp Lowell, LLC(4) |
Explanation of Responses: |
1. The reporting person's domestic partner is the trustee of the Amygdala Lange Trust. The reporting person disclaims beneficial ownership of such securities, and the inclusion of these securities in this report shall not be deemed an admission of beneficial ownership of such securities for purposes of Section 16 or for any other purposes. |
2. The reporting person's domestic partner is the trustee of the Lange Minors' Trust. The reporting person disclaims beneficial ownership of such securities, and the inclusion of these securities in this report shall not be deemed an admission of beneficial ownership of such securities for purposes of Section 16 or for any other purposes. |
3. The reporting person is a general partner of Asset Management Ventures Fund, L.P. ("AMVF L.L.P."), and has shared voting and dispositive power over the shares held by AMVF L.L.P. The reporting person disclaims beneficial ownership over such securities except to the extent of his pecuniary interest therein, and the inclusion of such securities in this report shall not be deemed an admission of beneficial ownership of the reported securities for purposes of Section 16 or for any other purposes. |
4. The reporting person is the president of Camp Lowell, LLC ("Camp Lowell"), and has sole voting and dispositive power over the shares held by Camp Lowell. The reporting person disclaims beneficial ownership over such securities except to the extent of his pecuniary interest therein, and the inclusion of such securities in this report shall not be deemed an admission of beneficial ownership of the reported securities for purposes of Section 16 or for any other purposes. |
5. Each share of the issuer's Series B Preferred Stock will automatically convert into 1 share of the issuer's Common Stock immediately upon the closing of the issuer's initial public offering and has no expiration date. |
Remarks: |
/s/ Thomas Soloway as attorney-in-fact for Louis Lange, M.D., Ph.D. | 07/19/2016 | |
** 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. |