SEC Form 4
| FORM 4 | UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP 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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| Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). | |||||||||||||||||
1. Name and Address of Reporting Person*
(Street)
| 2. Issuer Name and Ticker or Trading Symbol Forty Seven, Inc. [ FTSV ] | 5. Relationship of Reporting Person(s) to Issuer (Check all applicable)
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| 3. Date of Earliest Transaction (Month/Day/Year) 07/22/2019 | ||||||||||||||||||||||||||
| 4. 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 Acquired, Disposed of, or Beneficially Owned | ||||||||||
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| 1. Title of Security (Instr. 3) | 2. Transaction Date (Month/Day/Year) | 2A. Deemed Execution Date, if any (Month/Day/Year) | 3. Transaction Code (Instr. 8) | 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) | 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) | 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 7. Nature of Indirect Beneficial Ownership (Instr. 4) | |||
| Code | V | Amount | (A) or (D) | Price | ||||||
| Common Stock | 07/22/2019 | P | 312,500 | A | $8 | 2,786,868 | I | By Lightspeed Venture Partners X, L.P.(1) | ||
| Common Stock | 07/22/2019 | P | 312,500 | A | $8 | 2,096,769 | I | By Lightspeed Venture Partners Select II, L.P.(2) | ||
| Common Stock | 67,036 | I | By Lightspeed Affiliates X, L.P.(1) | |||||||
| Common Stock | 66,743 | I | By Ravi Mhatre | |||||||
| Common Stock | 66,743 | I | By Mhatre Investments LP - Fund 1(3) | |||||||
| Common Stock | 33,372 | I | By Mhatre 2011 Irrevocable Children's Trust(4) | |||||||
| Common Stock | 67,500 | I | By Peter Nieh | |||||||
| Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||||||||||
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| 1. Title of Derivative Security (Instr. 3) | 2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) | 6. Date Exercisable and Expiration Date (Month/Day/Year) | 7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4) | 8. Price of Derivative Security (Instr. 5) | 9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) | 10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 11. Nature of Indirect Beneficial Ownership (Instr. 4) | ||||
| Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||||||
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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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. Lightspeed General Partner X, L.P. ("Lightspeed GP X") is the general partner of Lightspeed Venture Partners X, L.P. ("Lightspeed X") and Lightspeed Affiliates X, L.P. ("Lightspeed Affiliates"). Lightspeed Ultimate General Partner X, Ltd. ("Lightspeed UGP X") is the general partner of Lightspeed GP X. Barry Eggers, Jeremy Liew, Ravi Mhatre and Peter Nieh are the directors of Lightspeed UGP X and share voting and dispositive power with respect to the shares held by Lightspeed X and Lightspeed Affiliates. Messrs. Eggers, Liew, Mhatre and Nieh disclaim beneficial ownership of the shares held by Lightspeed X and Lightspeed Affiliates except to the extent of their pecuniary interest therein. |
| 2. Lightspeed General Partner Select II, L.P. ("Select II GP") is the general partner of Lightspeed Venture Partners Select II, L.P. ("Lightspeed Select II"). Lightspeed Ultimate General Partner Select II, Ltd. ("Select II UGP") is the general partner of Select II GP. Barry Eggers, Jeremy Liew, Ravi Mhatre and Peter Nieh are the directors of Select II UGP and share voting and dispositive power with respect to the shares held by Lightspeed Select II. Messrs. Eggers, Liew, Mhatre and Nieh disclaim beneficial ownership of the shares held by Lightspeed Select II except to the extent of their pecuniary interest therein. |
| 3. Ravi Mhatre serves as trustee of the general partner of Mhatre Investments LP- Fund 1. |
| 4. Ravi Mhatre serves as trustee of Mhatre 2011 Irrevocable Children's Trust. |
| LIGHTSPEED VENTURE PARTNERS X, L.P. By: Lightspeed General Partner X, L.P., its general partner By: Lightspeed Ultimate General Partner X, Ltd., its general partner By: Duly Authorized Signatory /s/ Ravi Mhatre | 07/24/2019 | |
| LIGHTSPEED GENERAL PARTNER X, L.P. By: Lightspeed Ultimate General Partner X, Ltd., its general partner By: Duly Authorized Signatory /s/ Ravi Mhatre | 07/24/2019 | |
| LIGHTSPEED ULTIMATE GENERAL PARTNER X, LTD. By: Duly Authorized Signatory /s/ Ravi Mhatre | 07/24/2019 | |
| LIGHTSPEED VENTURE PARTNERS SELECT II, L.P. By: Lightspeed General Partner Select II, L.P., its general partner By: Lightspeed Ultimate General Partner Select II, Ltd., its general partner By: Duly Authorized Signatory /s/ Ravi Mhatre | 07/24/2019 | |
| LIGHTSPEED GENERAL PARTNER SELECT II, L.P. By: Lightspeed Ultimate General Partner Select II, Ltd., its general partner By: Duly Authorized Signatory /s/ Ravi Mhatre | 07/24/2019 | |
| LIGHTSPEED ULTIMATE GENERAL PARTNER SELECT II, LTD. By: Duly Authorized Signatory /s/ Ravi Mhatre | 07/24/2019 | |
| /s/ Barry Eggers | 07/24/2019 | |
| /s/ Jeremy Liew | 07/24/2019 | |
| /s/ Ravi Mharte | 07/24/2019 | |
| /s/ Peter Nieh | 07/24/2019 | |
| ** 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 4 (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. | ||