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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | |||
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 control number. | SEC 1474 (9-02) |
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 Underlying Securities (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 of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
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Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||||||
Series A Convertible Preferred Stock | (1) | 11/19/2014 | C | 225,000 | (1) | (1) | Common Stock | 90,000 | (1) | 0 | D | ||||
Series B Convertible Preferred Stock | (1) | 11/19/2014 | C | 150,177 | (1) | (1) | Common Stock | 60,070 | (1) | 0 | I | See footnote (4) | |||
Series E Convertible Preferred Stock | (1) | 11/19/2014 | C | 334,074 | (1) | (1) | Common Stock | 133,629 | (1) | 0 | I | See footnote (4) | |||
Series RA Convertible Preferred Stock | (1) | 11/19/2014 | C | 100,000 | (1) | (1) | Common Stock | 40,000 | (1) | 0 | I | See footnote (4) | |||
Series F Convertible Preferred Stock | (1) | 11/19/2014 | C | 50,000 | (1) | (1) | Common Stock | 20,000 | (1) | 0 | D |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
RIGGS RORY B C/O FIBROGEN, INC. 409 ILLINOIS ST. SAN FRANCISCO, CA 94158 |
X |
/s/ John Alden, Attorney-in-fact | 11/21/2014 | |
**Signature of Reporting Person | Date |
* | 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). |
(1) | Each share of the issuer's Series A Preferred Stock, Series B Preferred Stock, Series E Preferred Stock, Series RA Preferred Stock and Series F Preferred Stock automatically converted into 0.4 of a share of common stock immediately prior to the closing of the issuer's initial public offering, and has no expiration date. |
(2) | Includes 20,000 shares the reporting person holds jointly with his spouse. |
(3) | Shares are held by New Ventures I, LLC. The reporting person is Managing Member of New Ventures I, LLC and has voting and investment control with respect to the shares held by New Ventures I, LLC. |
(4) | Shares were held by New Ventures I, LLC. The reporting person is Managing Member of New Ventures I, LLC and has voting and investment control with respect to the shares held by New Ventures I, LLC. |