0001209191-21-029115.txt : 20210429
0001209191-21-029115.hdr.sgml : 20210429
20210429194505
ACCESSION NUMBER: 0001209191-21-029115
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20210427
FILED AS OF DATE: 20210429
DATE AS OF CHANGE: 20210429
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: HAQUE PROMOD
CENTRAL INDEX KEY: 0001089744
STATE OF INCORPORATION: CA
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-40353
FILM NUMBER: 21873042
MAIL ADDRESS:
STREET 1: C/O NORWEST VENTURE PARTNERS
STREET 2: 525 UNIVERSITY AVENUE, SUITE 800
CITY: PALO ALTO
STATE: CA
ZIP: 94301
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Crowe Jeffrey
CENTRAL INDEX KEY: 0001535261
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-40353
FILM NUMBER: 21873043
MAIL ADDRESS:
STREET 1: 525 UNIVERSITY AVENUE
STREET 2: SUITE 800
CITY: PALO ALTO
STATE: CA
ZIP: 94301
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Norwest Venture Partners XIV, LP
CENTRAL INDEX KEY: 0001842721
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-40353
FILM NUMBER: 21873044
BUSINESS ADDRESS:
STREET 1: 525 UNIVERSITY AVENUE
STREET 2: SUITE 800
CITY: PALO ALTO
STATE: CA
ZIP: 94301
BUSINESS PHONE: 650-321-8000
MAIL ADDRESS:
STREET 1: 525 UNIVERSITY AVENUE
STREET 2: SUITE 800
CITY: PALO ALTO
STATE: CA
ZIP: 94301
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Kossow Jon Erik
CENTRAL INDEX KEY: 0001726084
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-40353
FILM NUMBER: 21873041
MAIL ADDRESS:
STREET 1: 525 UNIVERSITY AVENUE, SUITE 800
CITY: PALO ALTO
STATE: CA
ZIP: 94025
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: IMPEL NEUROPHARMA INC
CENTRAL INDEX KEY: 0001445499
STANDARD INDUSTRIAL CLASSIFICATION: PHARMACEUTICAL PREPARATIONS [2834]
IRS NUMBER: 263058238
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
BUSINESS ADDRESS:
STREET 1: 201 ELLIOTT AVE. W
STREET 2: SUITE 260
CITY: SEATTLE
STATE: WA
ZIP: 98119
BUSINESS PHONE: 206-568-1466
MAIL ADDRESS:
STREET 1: 201 ELLIOTT AVE. W
STREET 2: SUITE 260
CITY: SEATTLE
STATE: WA
ZIP: 98119
4
1
doc4.xml
FORM 4 SUBMISSION
X0306
4
2021-04-27
0
0001445499
IMPEL NEUROPHARMA INC
IMPL
0001842721
Norwest Venture Partners XIV, LP
525 UNIVERSITY AVENUE
SUITE 800
PALO ALTO
CA
94301
0
0
1
0
0001535261
Crowe Jeffrey
525 UNIVERSITY AVENUE
SUITE 800
PALO ALTO
CA
94301
0
0
1
0
0001089744
HAQUE PROMOD
525 UNIVERSITY AVENUE
SUITE 800
PALO ALTO
CA
94301
0
0
1
0
0001726084
Kossow Jon Erik
525 UNIVERSITY AVENUE
SUITE 800
PALO ALTO
CA
94301
0
0
1
0
Common Stock
2021-04-27
4
C
0
98927
13.50
A
98927
D
Common Stock
2021-04-27
4
C
0
2153271
0.00
A
2252198
D
Common Stock
2021-04-27
4
P
0
825000
15.00
A
3077198
D
5% Convertible Note due 2021
13.50
2021-04-27
4
C
0
1325893.04
0.00
D
2021-12-31
Common Stock
98927
0
D
Series D Preferred Stock
2021-04-27
4
C
0
35256206
0.00
D
Common Stock
2153271
0
D
The securities shown represent securities held of record by Norwest Venture Partners XIV, LP ("NVP XIV"). Genesis VC Partners XIV, LLC ("Genesis XIV") is the general partner of NVP XIV and may be deemed to have sole voting and dispositive power over the shares held by NVP XIV. NVP Associates, LLC ("NVP Associates"), the managing member of Genesis XIV, and Jeffrey Crowe, Promod Haque and Jon E. Kossow, as Co-Chief Executive Officers of NVP Associates, may be deemed to share voting and dispositive power with respect to such securities. Such entities and Messrs. Crowe, Haque and Kossow disclaim beneficial ownership of all such securities, except to the extent of any pecuniary interest therein.
The shares of the Issuer's Series D Preferred Stock automatically converted into the number of shares of the Issuer's Common Stock on a 16.37332-for-one basis, for no additional consideration, immediately prior to the closing of the Issuer's initial public offering of Common Stock (the "IPO") and had no expiration date.
The convertible promissory note was issued by the Issuer in March 2021 and the outstanding principal and accrued interest automatically converted into the number of shares of the Issuer's Common Stock set forth above upon the closing of the IPO at $13.50 per share (90% of the IPO price).
/s/ Matthew De Dominicis, Chief Financial Officer
2021-04-29
/s/ Matthew De Dominicis, Attorney-in-Fact for Jeffrey Crowe
2021-04-29
/s/ Matthew De Dominicis, Attorney-in-Fact for Promod Haque
2021-04-29
/s/ Matthew De Dominicis, Attorney-in-Fact for Jon Erik Kossow
2021-04-29