Wendell Wierenga Form 3 Dermata Therapeutics / WENDELL WIERENGA ownership change

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^*

WIERENGA WENDELL

(Last) (First) (Middle)

3525 DEL MAR HEIGHTS RD., #332

(Street)

SAN DIEGO CA 92130

(City) (State) (Zip)

2. Date of Event Requiring Statement (Month/Day/Year)
08/12/2021

3. Issuer Name and Ticker or Trading Symbol
Dermata Therapeutics, Inc. [ DRMA ]

4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)

X	Director	10% Owner
	Officer (give title below)	Other (specify below)

5. If Amendment, Date of Original Filed (Month/Day/Year)

6. Individual or Joint/Group Filing (Check Applicable Line)

X	Form filed by One Reporting Person
	Form filed by More than One Reporting Person

Table I - Non-Derivative Securities Beneficially Owned
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	4,878(1)	D

Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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
Stock Option (Right to Buy)	03/31/2021	03/31/2031	Common Stock	12,194(1)	5.74	D
Stock Option (Right to Buy)	(2)	03/31/2031	Common Stock	4,878(1)	5.74	D
Series 1d Preferred Stock	(3)	(3)	Common Stock	55,078(3)	(3)	D

Explanation of Responses:

1. Shares reported reflect the 1 for 20.5 stock split effected July 1, 2021 (the "Stock Split").

2. Options vest in 12 equal monthly installments commencing January 1, 2021.

3. The Series 1d Preferred Stock is convertible into shares of Common Stock at a conversion ratio equal to 80% of the offering price in connection with the Issuer's initial public offering ("IPO"). Upon filing of the Issuer's Restated Certificate of Incorporation in connection with the IPO, all shares of Series 1d Preferred Stock will be converted into 8,163 shares of Common Stock of the Issuer. The conversion ratio reflects the Stock Split.

Remarks:

Exhibit 24. Power of Attorney

	/s/ Gerald T. Proehl, Attorney-in Fact	08/12/2021
	** 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).
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