0001209191-18-039609.txt : 20180627 0001209191-18-039609.hdr.sgml : 20180627 20180627143345 ACCESSION NUMBER: 0001209191-18-039609 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 2 CONFORMED PERIOD OF REPORT: 20180627 FILED AS OF DATE: 20180627 DATE AS OF CHANGE: 20180627 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Clarus Lifesciences III, L.P. CENTRAL INDEX KEY: 0001597143 STATE OF INCORPORATION: DE FISCAL YEAR END: 1214 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38554 FILM NUMBER: 18921471 BUSINESS ADDRESS: STREET 1: 101 MAIN STREET STREET 2: SUITE 1210 CITY: CAMBRIDGE STATE: MA ZIP: 02142 BUSINESS PHONE: 617-949-2200 MAIL ADDRESS: STREET 1: 101 MAIN STREET STREET 2: SUITE 1210 CITY: CAMBRIDGE STATE: MA ZIP: 02142 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Clarus Ventures III GP, L.P. CENTRAL INDEX KEY: 0001620148 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38554 FILM NUMBER: 18921472 BUSINESS ADDRESS: STREET 1: C/O CLARUS VENTURES STREET 2: 101 MAIN STREET, SUITE 1210 CITY: CAMBRIDGE STATE: MA ZIP: 02142 BUSINESS PHONE: 617-949-2200 MAIL ADDRESS: STREET 1: C/O CLARUS VENTURES STREET 2: 101 MAIN STREET, SUITE 1210 CITY: CAMBRIDGE STATE: MA ZIP: 02142 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Clarus Ventures III, LLC CENTRAL INDEX KEY: 0001664942 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38554 FILM NUMBER: 18921473 BUSINESS ADDRESS: STREET 1: 101 MAIN STREET STREET 2: SUITE 1210 CITY: CAMBRIDGE STATE: MA ZIP: 02142 BUSINESS PHONE: 6179492200 MAIL ADDRESS: STREET 1: 101 MAIN STREET STREET 2: SUITE 1210 CITY: CAMBRIDGE STATE: MA ZIP: 02142 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: HENNER DENNIS CENTRAL INDEX KEY: 0001249153 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38554 FILM NUMBER: 18921474 MAIL ADDRESS: STREET 1: THE JOHN HANCOCK TOWER STREET 2: 200 CLARENDON STREET, 54TH FLOOR CITY: BOSTON STATE: MA ZIP: 02116 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: GALAKATOS NICHOLAS CENTRAL INDEX KEY: 0001252522 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38554 FILM NUMBER: 18921475 MAIL ADDRESS: STREET 1: THE JOHN HANCOCK TOWER STREET 2: 200 CLARENDON STREET, 54TH FLOOR CITY: BOSTON STATE: MA ZIP: 02116 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: LIPTAK ROBERT CENTRAL INDEX KEY: 0001252523 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38554 FILM NUMBER: 18921476 MAIL ADDRESS: STREET 1: THE JOHN HANCOCK TOWER STREET 2: 200 CLARENDON STREET, 54TH FLOOR CITY: BOSTON STATE: MA ZIP: 02116 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Simon Nicholas CENTRAL INDEX KEY: 0001431403 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38554 FILM NUMBER: 18921477 MAIL ADDRESS: STREET 1: 101 MAIN STREET SUITE 1210 CITY: CAMBRIDGE STATE: MA ZIP: 02142 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Requadt Scott CENTRAL INDEX KEY: 0001664852 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38554 FILM NUMBER: 18921478 MAIL ADDRESS: STREET 1: 101 MAIN STREET, SUITE 1210 CITY: CAMBRIDGE STATE: MA ZIP: 02142 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: WHEELER KURT CENTRAL INDEX KEY: 0001252525 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38554 FILM NUMBER: 18921479 MAIL ADDRESS: STREET 1: 801 GATEWAY BLVD STREET 2: STE 410 CITY: SAN FRANCISCO STATE: CA ZIP: 94080 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 0001597143 Clarus Lifesciences III, L.P. 101 MAIN STREET, 12TH FLOOR CAMBRIDGE MA 02142 0 0 1 0 0001620148 Clarus Ventures III GP, L.P. 101 MAIN STREET, 12TH FLOOR CAMBRIDGE MA 02142 0 0 1 0 0001664942 Clarus Ventures III, LLC 101 MAIN STREET, 12TH FLOOR CAMBRIDGE MA 02142 0 0 1 0 0001249153 HENNER DENNIS 101 MAIN STREET, 12TH FLOOR CAMBRIDGE MA 02142 1 0 1 0 0001252522 GALAKATOS NICHOLAS 101 MAIN STREET, 12TH FLOOR CAMBRIDGE MA 02142 0 0 1 0 0001252523 LIPTAK ROBERT 101 MAIN STREET, 12TH FLOOR CAMBRIDGE MA 02142 0 0 1 0 0001431403 Simon Nicholas 101 MAIN STREET, 12TH FLOOR CAMBRIDGE MA 02142 0 0 1 0 0001664852 Requadt Scott 101 MAIN STREET, 12TH FLOOR CAMBRIDGE MA 02142 0 0 1 0 0001252525 WHEELER KURT 101 MAIN STREET, 12TH FLOOR CAMBRIDGE MA 02142 0 0 1 0 Series A-1 Preferred Stock Common Stock 938489 I See footnote Series A-2 Preferred Stock Common Stock 755780 I See footnote Series B Preferred Stock Common Stock 1922682 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. Clarus Ventures III GP, LP, or GPLP, as the sole general partner of Clarus Lifesciences III, LP, or Clarus, may be deemed to beneficially own certain of the shares held by Clarus. GPLP disclaims beneficial ownership of all shares held by Clarus in which the GPLP does not have a pecuniary interest. Clarus Ventures III, LLC, or GPLLC, as the sole general partner of the GPLP, may be deemed to beneficially own certain of the shares held by Clarus. GPLLC disclaims beneficial ownership of all shares held by Clarus in which it does not have an actual pecuniary interest. Each of Dennis Henner, Nicholas Galakatos, Robert Liptak, Nicholas Simon, Scott Requadt and Kurt Wheeler, as individual managing directors of GPLLC, may be deemed to beneficially own certain of the shares held of record by Clarus. Dr. Henner and Messrs. Galakatos, Liptak, Simon, Requadt and Wheeler disclaims beneficial ownership of all shares held of record by Clarus in which they do not have an actual pecuniary interest. Exhibit 24 - Power of Attorney Clarus Lifesciences III, L.P., by Clarus Ventures III GP, LP, its general partner, by Clarus Ventures III LLC, its general partner, /s/ Robert Liptak, Managing Director 2018-06-27 Clarus Ventures III GP, L.P., by Clarus Ventures III LLC, its general partner, /s/ Robert Liptak, Managing Director 2018-06-27 Clarus Ventures III LLC, /s/ Robert Liptak, Managing Director 2018-06-27 /s/ Dennis J. Henner 2018-06-27 /s/ Nicholas Galakatos 2018-06-27 /s/ Robert Liptak 2018-06-27 /s/ Nicholas Simon 2018-06-27 /s/ Scott Requadt 2018-06-27 /s/ Kurt Wheeler 2018-06-27 EX-24 2 attachment1.htm EX-24 DOCUMENT

POWER OF ATTORNEY


KNOW ALL BY THESE PRESENTS, that each person whose signature appears below
hereby constitutes and appoints Robert Liptak with full power to act singly, his
true and lawful attorney-in-fact, with full power of substitution, to: (i) sign
any and all instruments, certificates and documents that may be necessary,
desirable or appropriate to be executed on behalf of himself as an individual or
in his capacity as a general partner of any partnership or limited liability
company, pursuant to Section 13 or 16 of the Securities Exchange Act of 1934, as
amended, and any and all regulations promulgated thereunder, (ii) file the same
(including any amendments thereto), with all exhibits thereto, and any other
documents in connection therewith, with the Securities and Exchange Commission,
and any stock exchange or similar authority and (iii) take any other action of
any type whatsoever in connection with the foregoing which, in the opinion of
such attorney-in-fact, may be of benefit to, in the best interest of, or legally
required by, the undersigned, it being understood that the documents executed by
such attorney-in-fact on behalf of the undersigned pursuant to this power of
attorney shall be in such form and shall contain such terms and conditions as
such attorney-in-fact may approve in such attorney-in-fact's discretion,
granting unto said attorney-in-fact full power and authority to do and perform
each and every act and thing necessary, desirable or appropriate.
Each of the undersigned hereby grant to the attorney-in-fact full power and
authority to do and perform any and every act and thing whatsoever requisite,
necessary or proper to be done in the exercise of any of the rights and powers
herein granted, as fully to all intents and purposes as the undersigned might or
could do if personally present with full power of substitution or revocation,
hereby ratifying and confirming all that such attorney-in-fact or such
attorney-in-fact's substitute or substitutes, shall lawfully do or cause to be
done by virtue of this power of attorney and the rights and powers herein
granted.
This power of attorney shall remain in full force and effect until revoked by
the undersigned in a signed writing delivered to the attorney-in-fact.
IN WITNESS WHEREOF, this Power of Attorney has been signed as of the 9th day of
February, 2017.


/s/ Nicholas Galakatos
Nicholas Galakatos


/s/ Dennis Henner
Dennis Henner


/s/ Nick Simon
Nick Simon


/s/ Scott Requadt
Scott Requadt


/s/ Kurt Wheeler
Kurt Wheeler