0000899243-19-023893.txt : 20190918 0000899243-19-023893.hdr.sgml : 20190918 20190918214733 ACCESSION NUMBER: 0000899243-19-023893 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 2 CONFORMED PERIOD OF REPORT: 20190918 FILED AS OF DATE: 20190918 DATE AS OF CHANGE: 20190918 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: PALLARES EBETUEL CENTRAL INDEX KEY: 0001614597 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39049 FILM NUMBER: 191100910 MAIL ADDRESS: STREET 1: C/O EXAGEN DIAGNOSTICS, INC. STREET 2: 1261 LIBERTY WAY CITY: VISTA STATE: CA ZIP: 92081 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: EXAGEN INC. CENTRAL INDEX KEY: 0001274737 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-MEDICAL LABORATORIES [8071] IRS NUMBER: 000000000 STATE OF INCORPORATION: DE BUSINESS ADDRESS: STREET 1: 1261 LIBERTY WAY CITY: VISTA STATE: CA ZIP: 92081 BUSINESS PHONE: (760) 560-1501 MAIL ADDRESS: STREET 1: 1261 LIBERTY WAY CITY: VISTA STATE: CA ZIP: 92081 FORMER COMPANY: FORMER CONFORMED NAME: EXAGEN DIAGNOSTICS INC DATE OF NAME CHANGE: 20031230 3 1 doc3.xml FORM 3 SUBMISSION X0206 3 2019-09-18 0 0001274737 EXAGEN INC. XGN 0001614597 PALLARES EBETUEL C/O EXAGEN INC. 1261 LIBERTY WAY, SUITE C VISTA CA 92081 1 0 0 0 Common Stock 179 I See footnote Warrants 688.63 Common Stock 199 I See footnote Warrants 1.84 Common Stock 22427 I See footnote Warrants 1.84 Common Stock 2265 I See footnote Warrants 14.3235 Series E Redeemable Convertible Preferred Stock 219978 I See footnote Series E Redeemable Convertible Preferred Stock Common Stock 77204 I See footnote Series F Redeemable Convertible Preferred Stock Common Stock 43405 I See footnote The shares reported on this form are held of record by PCM/Exagen, L.P. ("PCM"). Ebetuel Pallares is a co-manager of PCM. As a result, each of PCM and Dr. Pallares may be deemed to share beneficial ownership of the shares held of record by PCM. The warrants are currently exercisable and will terminate upon closing of the Issuer's initial public offering. The warrants are currently exercisable and will expire on January 19, 2026. The warrants are currently exercisable and will expire on March 31, 2026. The Series E Redeemable Convertible Preferred Stock (the "Series E") is convertible into the Issuer's Common Stock on a 57.294-for-one basis at the holder's election and has no expiration date. The Series E will automatically convert into Commons Stock upon the closing of the Issuer's initial public offering. The Series F Redeemable Convertible Preferred Stock ("Series F") is convertible into the Issuer's Common Stock on a 183.635-for-one basis at the holder's election and has no expiration date. The Series F will automatically convert into Commons Stock upon the closing of the Issuer's initial public offering. Exhibit List: Exhibit 24 - Power of Attorney /s/ Kamal Adawi, Attorney-in-Fact 2019-09-18 EX-24 2 attachment1.htm EX-24 DOCUMENT

                               POWER OF ATTORNEY

      Know all by these presents, that the undersigned hereby constitutes and
appoints each of Fortunato Ron Rocca, Kamal Adawi and Mark Hazeltine, signing
singly, with full power of substitution, as the undersigned's true and lawful
attorney-in-fact to:

      (1)   prepare, execute in the undersigned's name and on the undersigned's
      behalf, and submit to the U.S. Securities and Exchange Commission (the
      "SEC") a Form ID, including amendments thereto, and any other documents
      necessary or appropriate to obtain codes and passwords enabling the
      undersigned to make electronic filings with the SEC of reports required by
      Section 16(a) of the Securities Exchange Act of 1934 or any rule or
      regulation of the SEC;

      (2)   execute for and on behalf of the undersigned, in the undersigned's
      capacity as an officer and/or director of Exagen Inc., a Delaware
      corporation (the "Company"), and/or 10% holder of the Company's capital
      stock, Forms 3, 4, and 5 and any amendments thereto in accordance with
      Section 16(a) of the Securities Exchange Act of 1934 and the rules
      thereunder;

      (3)   do and perform any and all acts for and on behalf of the undersigned
      which may be necessary or desirable to complete and execute any such Form
      3, 4, or 5, complete and execute any amendment or amendments thereto, and
      timely file such form with the SEC and any stock exchange or similar
      authority; and

      (4)   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.

      The undersigned hereby grants to each such 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. The undersigned acknowledges that the foregoing attorneys-in-fact, in
serving in such capacity at the request of the undersigned, are not assuming,
nor is the Company assuming, any of the undersigned's responsibilities to comply
with Section 16 of the Securities Exchange Act of 1934.

      This Power of Attorney shall remain in full force and effect until the
undersigned is no longer required to file Forms 3, 4, and 5 with respect to the
undersigned's holdings of and transactions in securities issued by the Company,
unless earlier revoked by the undersigned in a signed writing delivered to the
foregoing attorneys-in-fact.

      IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to
be executed as of this 17th day of September, 2019.


Signature:  /s/ Ebetuel Pallares
           --------------------------------
Print Name:  Ebetuel Pallares