0000899243-19-024082.txt : 20190923 0000899243-19-024082.hdr.sgml : 20190923 20190923214542 ACCESSION NUMBER: 0000899243-19-024082 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20190919 FILED AS OF DATE: 20190923 DATE AS OF CHANGE: 20190923 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: PALLARES EBETUEL CENTRAL INDEX KEY: 0001614597 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39049 FILM NUMBER: 191109083 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 FISCAL YEAR END: 1231 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 4 1 doc4.xml FORM 4 SUBMISSION X0306 4 2019-09-19 0 0001274737 EXAGEN INC. XGN 0001614597 PALLARES EBETUEL C/O EXAGEN INC. 1261 LIBERTY WAY VISTA CA 92081 1 0 0 0 Common Stock 2019-09-19 4 X 0 3839 14.3235 A 4018 I See footnote Common Stock 2019-09-19 4 F 0 2960 18.58 D 1058 I See footnote Common Stock 2019-09-23 4 C 0 120609 0.00 A 121667 I See footnote Warrants 14.3235 2019-09-19 4 X 0 3839 14.3235 D Common Stock 3839 0 I See footnote Series E Redeemable Convertible Preferred Stock 2019-09-23 4 C 0 4423371 D Common Stock 77204 0 I See footnote Series F Redeemable Convertible Preferred Stock 2019-09-23 4 C 0 7970686 D Common Stock 43405 0 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. Represents warrants that previously entitled the holders to purchase Series E Redeemable Convertible Preferred Stock, which, pursuant to their terms, were settled in shares of the Issuer's Common Stock. 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 automatically converted into Common 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 automatically converted into Common Stock upon the closing of the Issuer's initial public offering. /s/ Kamal Adawi, Attorney-in-Fact 2019-09-23