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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549ANNUAL STATEMENT 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 2270 (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 at End of Issuer's Fiscal Year (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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(A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | |||||||||
Series D Convertible Preferred Stock | Â | 12/20/2006 | Â | C4 | Â | 993,903 | Â (4) | Â (4) | Common Stock | $ 0 | 0 | See FN (3) |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Hozoji Hironori C/O AFFYMAX, INC. 4001 MIRANDA AVE. PALO ALTO, CA 94304 |
 X |  |  |  |
/s/ Ali Mahdavi, Attorney-in-Fact | 02/12/2007 | |
**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) | Automatic conversion, upon the closing of the Issuer's initial public offering, of Series D Preferred Stock ar a rate of 1 for 1, resulting in the issuance of 993,903 shares of common stock. |
(2) | The Series D Preferred Stock converted into the Issuer's common stock at a rate of 1 for 1. |
(3) | The shares are held as follows: 662,602 held by JAFCO Life Sciences No. 1 Investment Enterprise Partnership; 99,390 held by JAFCO V-1(A) Venture Capital Investment Limited Partnership; 165,650 held by JAFCO V-1(B) Venture Capital Investment Limited Partnership; and 66,261 held by JAFCO V-1 STAR Venture Capital Investment Limited Partnership (the "JAFCO Funds"). The reporting person holds shared voting or investment power of the shares held by each of the JAFCO Funds. The reporting person disclaims beneficial ownership of the shares except to the extent of his pecuniary interest therein. |
(4) | The securities are preferred stock of the Issuer and do not have an expiration date. The securities automatically converted into common stock upon the closing of the Issuer's initial public offering. |