0001209191-18-039617.txt : 20180627
0001209191-18-039617.hdr.sgml : 20180627
20180627145113
ACCESSION NUMBER: 0001209191-18-039617
CONFORMED SUBMISSION TYPE: 3
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20180627
FILED AS OF DATE: 20180627
DATE AS OF CHANGE: 20180627
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Lightspeed Venture Partners X, L.P.
CENTRAL INDEX KEY: 0001602573
STATE OF INCORPORATION: E9
FISCAL YEAR END: 1231
FILING VALUES:
FORM TYPE: 3
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-38554
FILM NUMBER: 18921554
BUSINESS ADDRESS:
STREET 1: 2200 SAND HILL ROAD
CITY: MENLO PARK
STATE: CA
ZIP: 94025
BUSINESS PHONE: 650-233-8300
MAIL ADDRESS:
STREET 1: 2200 SAND HILL ROAD
CITY: MENLO PARK
STATE: CA
ZIP: 94025
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Lightspeed Affiliates X, L.P.
CENTRAL INDEX KEY: 0001617751
STATE OF INCORPORATION: E9
FISCAL YEAR END: 1231
FILING VALUES:
FORM TYPE: 3
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-38554
FILM NUMBER: 18921555
BUSINESS ADDRESS:
STREET 1: 2200 SAND HILL ROAD
CITY: MENLO PARK
STATE: CA
ZIP: 94025
BUSINESS PHONE: 650-234-8300
MAIL ADDRESS:
STREET 1: 2200 SAND HILL ROAD
CITY: MENLO PARK
STATE: CA
ZIP: 94025
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Lightspeed General Partner X, L.P.
CENTRAL INDEX KEY: 0001700550
STATE OF INCORPORATION: E9
FISCAL YEAR END: 1231
FILING VALUES:
FORM TYPE: 3
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-38554
FILM NUMBER: 18921556
BUSINESS ADDRESS:
STREET 1: 2200 SAND HILL ROAD
CITY: MENLO PARK
STATE: CA
ZIP: 94025
BUSINESS PHONE: (650) 234-8300
MAIL ADDRESS:
STREET 1: 2200 SAND HILL ROAD
CITY: MENLO PARK
STATE: CA
ZIP: 94025
FORMER NAME:
FORMER CONFORMED NAME: Lightspeed General Partner X, L,P.
DATE OF NAME CHANGE: 20170310
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Lightspeed Ultimate General Partner X, Ltd.
CENTRAL INDEX KEY: 0001700549
STATE OF INCORPORATION: E9
FISCAL YEAR END: 1231
FILING VALUES:
FORM TYPE: 3
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-38554
FILM NUMBER: 18921557
BUSINESS ADDRESS:
STREET 1: 2200 SAND HILL ROAD
CITY: MENLO PARK
STATE: CA
ZIP: 94025
BUSINESS PHONE: (650) 234-8300
MAIL ADDRESS:
STREET 1: 2200 SAND HILL ROAD
CITY: MENLO PARK
STATE: CA
ZIP: 94025
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: SCHAEPE CHRISTOPHER J
CENTRAL INDEX KEY: 0001185068
FILING VALUES:
FORM TYPE: 3
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-38554
FILM NUMBER: 18921558
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Eggers Barry
CENTRAL INDEX KEY: 0001366048
FILING VALUES:
FORM TYPE: 3
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-38554
FILM NUMBER: 18921559
MAIL ADDRESS:
STREET 1: 2200 SAND HILL ROAD
CITY: MENLO PARK
STATE: CA
ZIP: 94025
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Nieh Peter
CENTRAL INDEX KEY: 0001366051
FILING VALUES:
FORM TYPE: 3
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-38554
FILM NUMBER: 18921560
MAIL ADDRESS:
STREET 1: 2200 SAND HILL ROAD
CITY: MENLO PARK
STATE: CA
ZIP: 94025
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Mhatre Ravi
CENTRAL INDEX KEY: 0001366050
FILING VALUES:
FORM TYPE: 3
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-38554
FILM NUMBER: 18921561
MAIL ADDRESS:
STREET 1: 2200 SAND HILL ROAD
CITY: MENLO PARK
STATE: CA
ZIP: 94025
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Liew Jeremy
CENTRAL INDEX KEY: 0001700539
FILING VALUES:
FORM TYPE: 3
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-38554
FILM NUMBER: 18921562
MAIL ADDRESS:
STREET 1: 2200 SAND HILL ROAD
CITY: MENLO PARK
STATE: CA
ZIP: 94025
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: Forty Seven, Inc.
CENTRAL INDEX KEY: 0001667633
STANDARD INDUSTRIAL CLASSIFICATION: PHARMACEUTICAL PREPARATIONS [2834]
IRS NUMBER: 474065674
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
BUSINESS ADDRESS:
STREET 1: 1490 O'BRIEN DRIVE, SUITE A
CITY: MENLO PARK
STATE: CA
ZIP: 94025
BUSINESS PHONE: (650) 352-4150
MAIL ADDRESS:
STREET 1: 1490 O'BRIEN DRIVE, SUITE A
CITY: MENLO PARK
STATE: CA
ZIP: 94025
3
1
doc3.xml
FORM 3 SUBMISSION
X0206
3
2018-06-27
0
0001667633
Forty Seven, Inc.
FTSV
0001602573
Lightspeed Venture Partners X, L.P.
2200 SAND HILL ROAD
MENLO PARK
CA
94025
0
0
1
0
0001617751
Lightspeed Affiliates X, L.P.
2200 SAND HILL ROAD
MENLO PARK
CA
94025
0
0
1
0
0001700550
Lightspeed General Partner X, L.P.
2200 SAND HILL ROAD
MENLO PARK
CA
94025
0
0
1
0
0001700549
Lightspeed Ultimate General Partner X, Ltd.
2200 SAND HILL ROAD
MENLO PARK
CA
94025
0
0
1
0
0001185068
SCHAEPE CHRISTOPHER J
2200 SAND HILL ROAD
MENLO PARK
CA
94025
1
0
1
0
0001366048
Eggers Barry
2200 SAND HILL ROAD
MENLO PARK
CA
94025
0
0
1
0
0001366051
Nieh Peter
2200 SAND HILL ROAD
MENLO PARK
CA
94025
0
0
1
0
0001366050
Mhatre Ravi
2200 SAND HILL ROAD
MENLO PARK
CA
94025
0
0
1
0
0001700539
Liew Jeremy
2200 SAND HILL ROAD
MENLO PARK
CA
94025
0
0
1
0
Series A-1 Preferred Stock
Common Stock
67036
I
See footnote
Series A-1 Preferred Stock
Common Stock
1340698
I
See footnote
Series A-2 Preferred Stock
Common Stock
1133670
I
See footnote
The Issuer's preferred stock will automatically convert into an equal number of shares of Issuer's common stock immediately upon the closing of the Issuer's initial public offering and has no expiration date.
Shares held by Lightspeed Affiliates X, L.P., or Lightspeed Affiliates.
Lightspeed General Partner X, L.P., or Lightspeed GP X, is the general partner of Lightspeed X and Lightspeed Affiliates. Lightspeed Ultimate General Partner X, Ltd., or Lightspeed UGP X, is the general partner of Lightspeed GP
X. Christopher J. Schaepe, Barry Eggers, Ravi Mhatre, Peter Nieh and Jeremy Liew are the directors of Lightspeed UGP X and share voting and dispositive power with respect to the shares held by Lightspeed X and Lightspeed Affiliates. Messrs. Schaepe, Eggers, Liew, Mhatre and Nieh disclaim beneficial ownership of the shares held by Lightspeed X and Lightspeed Affiliates except to the extent of their pecuniary interest therein.
Shares held by Lightspeed Venture Partners X, L.P., or Lightspeed X.
Lightspeed Venture Partners X, L.P., by Lightspeed General Partner X, L.P., its general partner, by Lightspeed Ultimate General Partner X, Ltd., its general partner, /s/ Christopher J. Schaepe, Duly authorized signatory
2018-06-27
Lightspeed Affiliates X, L.P., by Lightspeed General Partner X, L.P., its general partner, by Lightspeed Ultimate General Partner X, Ltd., its general partner, /s/ Christopher J. Schaepe, Duly authorized signatory
2018-06-27
Lightspeed General Partner X, L.P., by Lightspeed Ultimate General Partner X, Ltd., its general partner, /s/ Christopher J. Schaepe, Duly authorized signatory
2018-06-27
Lightspeed Ultimate General Partner X, Ltd., /s/ Christopher J. Schaepe, Duly authorized signatory
2018-06-27
/s/ Christopher J. Schaepe
2018-06-27
/s/ Barry Eggers
2018-06-27
/s/ Peter Nieh
2018-06-27
/s/ Ravi Mhatre
2018-06-27
/s/ Jeremy Liew
2018-06-27