0001209191-18-039618.txt : 20180627 0001209191-18-039618.hdr.sgml : 20180627 20180627145213 ACCESSION NUMBER: 0001209191-18-039618 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 Select II, L.P. CENTRAL INDEX KEY: 0001668017 STATE OF INCORPORATION: E9 FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38554 FILM NUMBER: 18921565 BUSINESS ADDRESS: STREET 1: 2200 SAND HILL ROAD CITY: MENLO PARK STATE: CA ZIP: 94025 BUSINESS PHONE: (650) 843-5000 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 Select II, L.P. CENTRAL INDEX KEY: 0001744936 STATE OF INCORPORATION: E9 FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38554 FILM NUMBER: 18921566 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 Ultimate General Partner Select II, Ltd. CENTRAL INDEX KEY: 0001744937 STATE OF INCORPORATION: E9 FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38554 FILM NUMBER: 18921567 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: 18921568 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: 18921569 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: 18921570 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: 18921571 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: 18921572 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 0001668017 Lightspeed Venture Partners Select II, L.P. 2200 SAND HILL ROAD MENLO PARK CA 94025 0 0 1 0 0001744936 Lightspeed General Partner Select II, L.P. 2200 SAND HILL ROAD MENLO PARK CA 94025 0 0 1 0 0001744937 Lightspeed Ultimate General Partner Select II, 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 B Preferred Stock Common Stock 1315519 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. Lightspeed General Partner Select II, L.P., or Select II GP, is the general partner of Lightspeed Venture Partners Select II, L.P., or Lightspeed Select II. Lightspeed Ultimate General Partner Select II, Ltd., or Select II UGP, is the general partner of Select II GP. Christopher J. Schaepe, Barry Eggers, Jeremy Liew, Ravi Mhatre and Peter Nieh are the directors of Select II UGP and share voting and dispositive power with respect to the shares held by Lightspeed Select II. Messrs. Schaepe, Eggers, Liew, Mhatre and Nieh disclaim beneficial ownership of the shares held by Lightspeed Select II except to the extent of their pecuniary interest therein. Lightspeed Venture Partners Select II, L.P., by Lightspeed General Partner Select II, L.P., its general partner, by Lightspeed Ultimate General Partner Select II, Ltd., its general partner, /s/ Christopher J. Schaepe, Duly authorized signatory 2018-06-27 Lightspeed General Partner Select II, L.P, by Lightspeed Ultimate General Partner Select II, Ltd., by /s/ Christopher J. Schaepe, Duly authorized signatory 2018-06-27 Lightspeed Ultimate General Partner Select II, Ltd., by /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