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