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) 11/01/2017 | 3. Issuer Name and Ticker or Trading Symbol Allena Pharmaceuticals, Inc. [ ALNA ] | |||||||||||||
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 A Preferred Stock | (1) | (2) | Common Stock | 1,466,805(1) | (1) | I | By Frazier Healthcare VI, L.P.(3) |
Series B Preferred Stock | (4) | (2) | Common Stock | 1,109,159(4) | (4) | I | By Frazier Healthcare VI, L.P.(3) |
Series C Preferred Stock | (5) | (2) | Common Stock | 254,409(5) | (5) | I | By Frazier Healthcare VI, L.P.(3) |
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. The Series A Preferred Stock is convertible into Common Stock of the Issuer at the option of the holder. The Series A Preferred Stock will automatically convert into Common Stock of the Issuer on a 4.174-to-1 basis upon closing of the initial public offering of the Issuer and the number of underlying shares of Common Stock reported in Column 3 reflects such conversion. |
2. Not applicable. |
3. The securities are held by Frazier Healthcare VI, L.P. ("Frazier VI"). FHM VI, L.P. ("FHM LP") is the general partner of Frazier VI and FHM VI, L.L.C. ("FHM LLC") is the general partner of FHM LP. Each of FHM LLC and FHM LP disclaims beneficial ownership of all shares held by Frazier VI except to the extent, if any, of such entity's, as applicable, pecuniary interest therein. |
4. The Series B Preferred Stock is convertible into Common Stock of the Issuer at the option of the holder. The Series B Preferred Stock will automatically convert into Common Stock of the Issuer on a 4.174-to-1 basis upon closing of the initial public offering of the Issuer and the number of underlying shares of Common Stock reported in Column 3 reflects such conversion. |
5. The Series C Preferred Stock is convertible into Common Stock of the Issuer at the option of the holder. The Series C Preferred Stock will automatically convert into Common Stock of the Issuer on a 4.174-to-1 basis upon closing of the initial public offering of the Issuer and the number of underlying shares of Common Stock reported in Column 3 reflects such conversion. |
Remarks: |
FHM VI, LLC, /s/ Steve Bailey, Chief Financial Officer | 11/01/2017 | |
FHM VI, L.P., By: FHM VI, L.L.C., its general partner, By: /s/ Steve Bailey, Chief Financial Officer | 11/01/2017 | |
Frazier Healthcare VI, L.P., By: FHM VI, L.P., its general partner, By: FHM VI, L.L.C., its general partner, By: /s/ Steve Bailey, Chief Financial Officer | 11/01/2017 | |
** 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. |