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)
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2. Issuer Name and Ticker or Trading Symbol
VAPOTHERM INC [ VAPO ] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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3. Date of Earliest Transaction
(Month/Day/Year) 11/16/2018 | ||||||||||||||||||||||||||
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 | 11/16/2018 | C | 1,262,504 | A | (1) | 1,262,504 | D | |||
Common Stock | 11/16/2018 | C | 35,713 | A | (6) | 1,298,217 | D |
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 | ||||||||
Series A Convertible Preferred Stock | (1) | 11/16/2018 | C | 372,206 | (1) | (1) | Common Stock | 372,206(2) | $0.00 | 0 | D | ||||
Series B Convertible Preferred Stock | (1) | 11/16/2018 | C | 145,252 | (1) | (1) | Common Stock | 145,252(3) | $0.00 | 0 | D | ||||
Series C Convertible Preferred Stock | (1) | 11/16/2018 | C | 430,937 | (1) | (1) | Common Stock | 430,937(4) | $0.00 | 0 | D | ||||
Series D Convertible Preferred Stock | (1) | 11/16/2018 | C | 314,109 | (1) | (1) | Common Stock | 314,109(5) | $0.00 | 0 | D | ||||
Series D-1 Convertible Preferred Stock | (6) | 11/16/2018 | C | 35,713 | (2) | (2) | Common Stock | 35,713(7) | $0.00 | 0 | D |
1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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Explanation of Responses: |
1. Upon closing of the Issuer's initial public offering, each share of Series A Convertible Preferred Stock, Series B Convertible Preferred Stock, Series C Convertible Preferred Stock and Series D Convertible Preferred Stock automatically converted into one share of Common Stock without payment or further consideration. There was no expiration date for the Series A Convertible Preferred Stock, the Series B Convertible Preferred Stock, the Series C Convertible Preferred Stock or the Series D Convertible Preferred Stock. |
2. Consists of (i) 163,365 shares held by SightLine Healthcare Opportunity Fund II, (ii) 56,994 shares held by SightLine Healthcare Opportunity Fund II-A and (iii) 151,847 shares held by SightLine Healthcare Opportunity Fund II-B. |
3. Consists of (i) 63,753 shares held by SightLine Healthcare Opportunity Fund II, (ii) 22,241 shares held by SightLine Healthcare Opportunity Fund II-A and (iii) 59,258 shares held by SightLine Healthcare Opportunity Fund II-B. |
4. Consists of (i) 189,144 shares held by SightLine Healthcare Opportunity Fund II, (ii) 65,986 shares held by SightLine Healthcare Opportunity Fund II-A and (iii) 175,807 shares held by SightLine Healthcare Opportunity Fund II-B. |
5. Consists of (i) 137,866 shares held by SightLine Healthcare Opportunity Fund II, (ii) 48,098 shares held by SightLine Healthcare Opportunity Fund II-A and (iii) 128,145 shares held by SightLine Healthcare Opportunity Fund II-B. |
6. Upon closing of the Issuer's initial public offering, each share of Series D-1 Convertible Preferred Stock automatically converted into 1.137 shares of Common Stock without payment or further consideration. There was no expiration date for the Series D-1 Convertible Preferred Stock. |
7. Consists of 35,713 shares held by SightLine Investors, LLC. |
Remarks: |
/s/ John Landry, as Attorney-In-Fact for, SightLine Partners LLC | 11/20/2018 | |
/s/ John Landry, as Attorney-In-Fact for, SightLine Healthcare Opportunity Fund II, L.P. | 11/20/2018 | |
/s/ John Landry, as Attorney-In-Fact for, SightLine Healthcare Opportunity Fund II-A, L.P. | 11/20/2018 | |
/s/ John Landry, as Attorney-In-Fact for, SightLine Healthcare Opportunity Fund II-B, L.P. | 11/20/2018 | |
/s/ John Landry, as Attorney-In-Fact for, SightLine Investors, LLC | 11/20/2018 | |
** 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. |