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