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) 08/01/2017 | 3. Issuer Name and Ticker or Trading Symbol Molecular Templates, Inc. [ MTEM ] | |||||||||||||
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
| 5. If Amendment, Date of Original Filed (Month/Day/Year) 08/11/2017 | ||||||||||||||
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 | 7,897,298 | I | Held by Sante Health Ventures I, L.P.(1) |
Common Stock | 864,665 | I | Held by Sante Health Ventures I Annex Fund, L.P.(1) |
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 | ||||
Warrants | 08/01/2017 | 08/01/2024 | Common Stock | 19,310 | 6.8423 | I(1) | Held by Sante Health Ventures I, L.P.(1) |
Warrants | 08/01/2017 | 08/01/2024 | Common Stock | 4,827 | 6.8423 | I(1) | Held by Sante Health Ventures I Annex Fund, L.P.(1) |
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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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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1. Name and Address of Reporting Person*
(Street)
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Explanation of Responses: |
1. The securities held by Sante Health Ventures I, L.P. and Sante Health Ventures I Annex Fund, L.P. may be deemed to be beneficially owned by Joe Cunningham, M.D. and Douglas D. French, who are managing directors (the "SHV Directors") of SHV Management Services, LLC ("SHV Management"). SHV Management is the general partner of SHV Management Services, LP, which is the general partner of Sante Health Ventures I, L.P., and SHV Annex Services, LP, which is the general partner of Sante Health Ventures I Annex Fund, L.P. Each of the SHV Directors, SHV Management, SHV Management Services, LP and SHV Annex Services, LP disclaims beneficial ownership of the reported securities except to the extent of his or its pecuniary interest therein. |
Remarks: |
(1) This amended Form 3 is being filed in order to add SHV Annex Services, LP ("Annex Services") as a Reporting Owner. Annex Services was disclosed in Explanation (1) above as the general partner of Sante Health Ventures I Annex Fund, L.P. but omitted on the table of Reporting Owners in the original filing on August 11, 2017. |
SHV MANAGEMENT SERVICES, LLC, By: Kevin Lalande, Its Managing Member, By: /s/ Jason S. Kim, Attorney in fact | 09/25/2017 | |
SHV MANAGEMENT SERVICES, L.P., By: SHV Management Services, LLC, Its general partner, By: Kevin Lalande, Its Managing Member, By: /s/ Jason S. Kim, Attorney in fact | 09/25/2017 | |
SANTE HEALTH VENTURES I, L.P., By: SHV Management Services, L.P., Its general partner, By: SHV Management Services, LLC, Its general partner, By: Kevin Lalande, Its Managing Member, By: /s/ Jason S. Kim, Attorney in fact | 09/25/2017 | |
SHV ANNEX SERVICES, L.P., By: SHV Management Services, LLC, Its general partner, By: Kevin Lalande, Its Managing Member, By: /s/ Jason S. Kim, Attorney in fact | 09/25/2017 | |
SANTE HEALTH VENTURES I ANNEX FUND, L.P., By: SHV Annex Services, LP, Its general partner, By: SHV Management Services, LLC, Its general partner, By: Kevin Lalande, Its Managing Member, By: /s/ Jason S. Kim, Attorney in fact | 09/25/2017 | |
JOE CUNNINGHAM, MD, By: /s/ Jason S. Kim, Attorney-in-Fact | 09/25/2017 | |
DOUGLAS D. FRENCH, By: /s/ Jason S. Kim, Attorney-in-Fact | 09/25/2017 | |
** 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. |