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)
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2. Date of Event Requiring Statement
(Month/Day/Year) 07/17/2019 |
3. Issuer Name and Ticker or Trading Symbol
Mirum Pharmaceuticals, Inc. [ MIRM ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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5. If Amendment, Date of Original Filed
(Month/Day/Year) |
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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 | 281,250 | I | By The Grey Family Trust dated November 12, 1999 |
Common Stock | 93,750 | I | By The Grey 2018 Irrevocable Children's Trust |
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 | ||||
Series A Preferred Stock | (1) | (1) | Common Stock | 7,948(2) | (1) | I | By The Grey Family Trust dated November 12, 1999 |
Stock Option (right to buy) | (3) | 03/11/2029 | Common Stock | 375,000 | $2.936 | D | |
Stock Option (right to buy) | (4) | 05/13/2029 | Common Stock | 262,500 | $6.272 | D |
Explanation of Responses: |
1. The shares of Series A Preferred Stock have no expiration date and are convertible at any time at the election of the holder without payment of further consideration. Each share of Series A Preferred Stock will automatically convert into 0.125 shares of Common Stock upon the closing of the Issuer's initial public offering. |
2. Share numbers give effect to the reverse split of each share of the Issuer's Common Stock into 0.125 shares of Common Stock effected on July 3, 2019, which will be effective for the Preferred Stock upon its conversion to Common Stock upon the closing of the Issuer's initial public offering. |
3. 1/4th of the shares vest one year after November 5, 2018, and the balance of the shares vest in a series of 36 successive equal monthly installments at the end of each month thereafter. The shares subject to this option are early exercisable, subject to the Issuer's right of repurchase. |
4. 1/4th of the shares vest one year after April 12, 2019 and the balance of the shares vest in a series of 36 successive equal monthly installments measured from the first anniversary of April 12, 2019. The shares subject to this option are early exercisable, subject to the Issuer's right of repurchase. |
Remarks: |
/s/ Jody Howe, Attorney-in-Fact | 07/17/2019 | |
** 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 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. |