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