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