0001144204-16-103217.txt : 20160517 0001144204-16-103217.hdr.sgml : 20160517 20160517211845 ACCESSION NUMBER: 0001144204-16-103217 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20160517 FILED AS OF DATE: 20160517 DATE AS OF CHANGE: 20160517 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: PHASERX, INC. CENTRAL INDEX KEY: 0001429386 STANDARD INDUSTRIAL CLASSIFICATION: PHARMACEUTICAL PREPARATIONS [2834] IRS NUMBER: 204690620 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 410 WEST HARRISON STREET STREET 2: SUITE 300 CITY: SEATTLE STATE: WA ZIP: 98119 BUSINESS PHONE: 206-805-6300 MAIL ADDRESS: STREET 1: 410 WEST HARRISON STREET STREET 2: SUITE 300 CITY: SEATTLE STATE: WA ZIP: 98119 FORMER COMPANY: FORMER CONFORMED NAME: PHASERX INC DATE OF NAME CHANGE: 20080311 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: ROCKLAGE SCOTT M CENTRAL INDEX KEY: 0001219014 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-37772 FILM NUMBER: 161659283 MAIL ADDRESS: STREET 1: 179 SANDY POND ROAD CITY: LINCOLN STATE: MA ZIP: 01773 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: DIEKMAN JOHN D CENTRAL INDEX KEY: 0001240357 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-37772 FILM NUMBER: 161659282 MAIL ADDRESS: STREET 1: C/O 5 AM VENTURES STREET 2: 3000 SAND HILL RD CITY: MENLO PARK STATE: CA ZIP: 94025 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: 5AM Ventures II LP CENTRAL INDEX KEY: 0001386509 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-37772 FILM NUMBER: 161659287 BUSINESS ADDRESS: STREET 1: 2200 SAND HILL RD STE 110 CITY: Menlo Park STATE: CA ZIP: 94025 BUSINESS PHONE: 650-233-8600 MAIL ADDRESS: STREET 1: 2200 SAND HILL RD STE 110 CITY: Menlo Park STATE: CA ZIP: 94025 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: 5AM CO-INVESTORS II LP CENTRAL INDEX KEY: 0001390376 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-37772 FILM NUMBER: 161659286 BUSINESS ADDRESS: STREET 1: 2200 SAND HILL RD STE 110 CITY: MENLO PK STATE: CA ZIP: 94025 BUSINESS PHONE: 650-233-8600 MAIL ADDRESS: STREET 1: 2200 SAND HILL RD STE 110 CITY: MENLO PK STATE: CA ZIP: 94025 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: 5AM Partners II, LLC CENTRAL INDEX KEY: 0001555952 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-37772 FILM NUMBER: 161659285 BUSINESS ADDRESS: STREET 1: 2200 SAND HILL ROAD STE 110 CITY: MENLO PARK STATE: CA ZIP: 94025 BUSINESS PHONE: 650.233.8600 MAIL ADDRESS: STREET 1: 2200 SAND HILL ROAD STE 110 CITY: MENLO PARK STATE: CA ZIP: 94025 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Schwab Andrew J. CENTRAL INDEX KEY: 0001598549 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-37772 FILM NUMBER: 161659284 MAIL ADDRESS: STREET 1: C/O 5AM VENTURES, 2200 SAND HILL ROAD STREET 2: SUITE 110 CITY: MENLO PARK STATE: CA ZIP: 94025 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Ulevitch Richard J CENTRAL INDEX KEY: 0001673244 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-37772 FILM NUMBER: 161659288 MAIL ADDRESS: STREET 1: 200 SAND HILL ROAD STREET 2: SUITE 110 CITY: MENLO PARK STATE: CA ZIP: 94025 3 1 v440251_form3.xml OWNERSHIP DOCUMENT X0206 3 2016-05-17 0 0001429386 PHASERX, INC. PZRX 0001673244 Ulevitch Richard J C/O 5AM PARTNERS II LLC 200 SAND HILL ROAD, SUITE 110 MENLO PARK CA 94025 1 0 1 0 0001386509 5AM Ventures II LP 200 SAND HILL ROAD, SUITE 110 MENLO PARK CA 94025 0 0 1 0 0001390376 5AM CO-INVESTORS II LP 200 SAND HILL ROAD, SUITE 110 MENLO PK CA 94025 0 0 1 0 0001555952 5AM Partners II, LLC 200 SAND HILL ROAD, SUITE 110 MENLO PARK CA 94025 0 0 1 0 0001598549 Schwab Andrew J. C/O 5AM PARTNERS II LLC 200 SAND HILL ROAD, SUITE 110 MENLO PARK CA 94025 0 0 1 0 0001219014 ROCKLAGE SCOTT M C/O 5AM PARTNERS II LLC 200 SAND HILL ROAD, SUITE 110 MENLO PARK CA 94025 0 0 1 0 0001240357 DIEKMAN JOHN D C/O 5AM PARTNERS II LLC 200 SAND HILL ROAD, SUITE 110 MENLO PARK CA 94025 0 0 1 0 Common Stock 1201390 I By 5AM Ventures II, LP Common Stock 47406 I By 5AM Co-Investors II, LP Warrants to Purchase Common Stock 7.96 2012-02-01 Common Stock 30208 I By 5AM Ventures II, LP Warrants to Purchase Common Stock 7.96 2012-02-01 Common Stock 1192 I By 5AM Co-Investors II, LP Reflects a 1-for-10.656096 reverse stock split effected on May 17, 2016. 5AM Partners II LLC is the general partner of each of 5AM Ventures II, LP and 5AM Co-Investors II, LP. (the "5AM Ventures") Andrew J. Schwab, John Diekman and Scott M. Rocklage are the managing members of 5AM Partners II LLC and are deemed to have voting and dispositive power over the shares and may be deemed to beneficially own shares held by 5AM Ventures. Dr. Ulevitch is a member of and owns an interest in 5AM Partners II LLC. Accordingly, Mr. Schwab, Dr. Diekman, Mr. Rocklage and Dr. Ulevitch may be deemed to beneficially own the securities held by 5AM Ventures. Mr. Schwab, Dr. Diekman, Mr. Rocklage and Dr. Ulevitch each disclaims beneficial ownership of these securities and this disclosure shall not be deemed an admission that Mr. Schwab, Dr. Diekman, Mr. Rocklage and Dr. Ulevitch is the beneficial owner of such securities for purposes of Section 13(d) of the Securities Exchange Act of 1934, as amended, or any other purpose. The warrants expire at the earlier to occur of (a) February 1, 2019 or (b) the initial public offering of the Issuer's common stock. /s/ Andrew J. Schwab, Managing Member of 5AM Partners II LLC 2016-05-17 /s/ Andrew J. Schwab, Managing Member of the general partner of 5AM Ventures II, LP 2016-05-17 /s/ Andrew J. Schwab, Managing Member of the general partner of 5AM Co-Investors II, LP 2016-05-17 /s/ Richard J. Ulevitch 2016-05-17 /s/ Andrew J. Schwab 2016-05-17 /s/ Scott M. Rocklage 2016-05-17 /s/ John Diekman 2016-05-17