CalciMedica (CALC) Form 3 GRAYBUG VISION / CHRISTY L SHAFFER 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^*

SHAFFER CHRISTY L

(Last) (First) (Middle)

C/O GRAYBUG VISION, INC.

275 SHORELINE DRIVE, SUITE 450

(Street)

REDWOOD CITY CA 94065

(City) (State) (Zip)

2. Date of Event Requiring Statement (Month/Day/Year)
09/24/2020

3. Issuer Name and Ticker or Trading Symbol
GRAYBUG VISION, INC. [ GRAY ]

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)

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
Series A-2 Preferred Stock	(1)	(1)	Common Stock	193,224	(1)	I	See footnote(2)
Series B Preferred Stock	(1)	(1)	Common Stock	1,242,120	(1)	I	See footnote(2)
Series C Preferred Stock	(1)	(1)	Common Stock	151,146	(1)	I	See footnote(2)
Stock Option (Right to Buy)	(3)	02/19/2025	Common Stock	33,089	1	I	See footnote(2)
Stock Option (Right to Buy)	(3)	05/08/2025	Common Stock	24,638	1	I	See footnote(2)

Explanation of Responses:

1. Each share of the Issuer's Series A-2 Preferred Stock, Series B Preferred Stock and Series C Preferred Stock will automatically convert into 1 share of the issuer's Common Stock immediately prior to the closing of the Issuer's initial public offering for no additional consideration and has no expiration date.

2. These securities are held of record by Hatteras Venture Partners IV SBIC, L.P. ("HVP IV SBIC"). Hatteras Venture Advisors IV SBIC, L.L.C. ("HVA IV SBIC") is the general partner of HVP IV SBIC. The managing members of HVA IV SBIC include: Robert Ingram, Douglas Reed, Clay Thorp, John Crumpler and Kenneth Lee. These managing members share voting and dispositive power over the securities directly held by HVP IV SBIC. The Reporting Person is a partner of Hatteras Venture Partners and disclaims beneficial ownership of the securities held by HVP IV SBIC except to the extent of her pecuniary interest therein, if any.

3. The stock options are fully vested.

Remarks:

	/s/ Frederic Guerard, as Attorney-in-Fact for Christy Shaffer	09/24/2020
	** 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.
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