0001209191-21-028361.txt : 20210426 0001209191-21-028361.hdr.sgml : 20210426 20210426175557 ACCESSION NUMBER: 0001209191-21-028361 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20210422 FILED AS OF DATE: 20210426 DATE AS OF CHANGE: 20210426 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: ROCKLAGE SCOTT M CENTRAL INDEX KEY: 0001219014 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-40353 FILM NUMBER: 21855246 MAIL ADDRESS: STREET 1: 179 SANDY POND ROAD CITY: LINCOLN STATE: MA ZIP: 01773 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Schwab Andrew J. CENTRAL INDEX KEY: 0001598549 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-40353 FILM NUMBER: 21855245 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: 5AM Partners V, LLC CENTRAL INDEX KEY: 0001791889 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-40353 FILM NUMBER: 21855248 BUSINESS ADDRESS: STREET 1: 501 SECOND STREET, SUITE 350 CITY: SAN FRANCISCO STATE: CA ZIP: 94107 BUSINESS PHONE: 650-233-8600 MAIL ADDRESS: STREET 1: 501 SECOND STREET, SUITE 350 CITY: SAN FRANCISCO STATE: CA ZIP: 94107 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: PARMAR KUSH CENTRAL INDEX KEY: 0001664281 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-40353 FILM NUMBER: 21855247 MAIL ADDRESS: STREET 1: C/O AUDENTES THERAPEUTICS, INC. STREET 2: 101 MONTGOMERY ST., SUITE 2650 CITY: SAN FRANCISCO STATE: CA ZIP: 94104 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: 5AM Ventures V, L.P. CENTRAL INDEX KEY: 0001674324 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-40353 FILM NUMBER: 21855249 BUSINESS ADDRESS: STREET 1: 2200 SAND HILL ROAD, SUITE 110 CITY: MENLO PARK STATE: CA ZIP: 94025 BUSINESS PHONE: (650) 233-8600 MAIL ADDRESS: STREET 1: 2200 SAND HILL ROAD, SUITE 110 CITY: MENLO PARK 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 2021-04-22 0 0001445499 IMPEL NEUROPHARMA INC IMPL 0001674324 5AM Ventures V, L.P. 501 2ND STREET, SUITE 350 SAN FRANCISCO CA 94107 0 0 1 0 0001791889 5AM Partners V, LLC 501 2ND STREET, SUITE 350 SAN FRANCISCO CA 94107 0 0 1 0 0001664281 PARMAR KUSH 501 2ND STREET, SUITE 350 SAN FRANCISCO CA 94107 0 0 1 0 0001219014 ROCKLAGE SCOTT M 501 2ND STREET, SUITE 350 SAN FRANCISCO CA 94107 0 0 1 0 0001598549 Schwab Andrew J. 501 2ND STREET, SUITE 350 SAN FRANCISCO CA 94107 0 0 1 0 5% Convertible Note due 2021 2021-04-22 4 J 0 1359799.28 0.00 A 2021-12-31 Common Stock 101457 1359799.28 I See Footnote The convertible promissory note (the "Note") was issued by the Issuer in March 2021 and the outstanding principal and accrued interest on the Note will automatically convert into the number of shares of Common Stock upon the closing of the initial public offering (the "IPO") at a conversion price of $13.50 per share (90% of the public offering price in the IPO). Because, at the time of the effectiveness of the Issuer's registration of its Common Stock under the Securities Exchange Act, the conversion price of the Note had not yet been determined, the Note was not reportable on the Reporting Persons' Form 3. The conversion price of the Note became fixed on April 22, 2021 upon the pricing of the IPO, which resulted in the Note becoming reportable under Section 16 of the Securities Exchange Act. Represents the principal amount of the Note. The shares are directly held by 5AM Ventures V, L.P. ("Ventures V"). 5AM Partners V, LLC ("Partners V") is the sole general partner of Ventures V. Andrew J. Schwab, Dr. Scott M. Rocklage and Dr. Kush Parmar, are the managing members of Partners V and may be deemed to have shared voting and investment power over the shares beneficially owned by Ventures V. Each of Partners V, Mr. Schwab, Dr. Rocklage and Dr. Parmar disclaims beneficial ownership of such shares except to the extent of its or his pecuniary interest therein. 5AM Ventures V, L.P., By: 5AM Partners V, LLC, its General Partner, By /s/ Scott M. Rocklage, Managing Member 2021-04-26 /s/ Scott M. Rocklage 2021-04-26 /s/ Kush Parmar 2021-04-26 /s/ Scott M. Rocklage 2021-04-26 /s/ Andrew J. Schwab 2021-04-26