FORM 3 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940 |
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1. Name and Address of Reporting Person*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 08/05/2010 |
3. Issuer Name and Ticker or Trading Symbol
NUPATHE INC. [ PATH ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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5. If Amendment, Date of Original Filed
(Month/Day/Year) |
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6. Individual or Joint/Group Filing (Check Applicable Line)
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Table I - Non-Derivative Securities Beneficially Owned | |||
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1. Title of Security (Instr. 4) | 2. Amount of Securities Beneficially Owned (Instr. 4) | 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 4. Nature of Indirect Beneficial Ownership (Instr. 5) |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
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1. Title of Derivative Security (Instr. 4) | 2. Date Exercisable and Expiration Date (Month/Day/Year) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 6. Nature of Indirect Beneficial Ownership (Instr. 5) | ||
Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Series A Convertible Preferred Stock | (1) | (1) | Common Stock | 160,990(2) | (1) | I | By Birchmere Ventures III TSIB LP(3) |
Series B Convertible Preferred Stock | (4) | (4) | Common Stock | 136,842(5) | (4) | I | By Birchmere Ventures III TSIB LP(3) |
Warrant to Purchase Series B Convertible Preferred Stock | 08/20/2009 | 08/20/2016 | Series B Convertible Preferred Stock | 19,549(6) | $0.93 | I | By Birchmere Ventures III TSIB LP(3) |
Convertible Promissory Notes | (7) | 12/31/2010 | Common Stock | 62,829(7) | $8 | I | By Birchmere Ventues III TSIB LP(3) |
1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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Explanation of Responses: |
1. The shares of Series A Convertible Preferred Stock (the "Series A Shares"), including all accrued and unpaid dividends thereon, will convert automatically into Common Stock on a 1-for-8.0149 basis upon the closing of the Issuer's initial public offering, and have no expiration date. |
2. Reflects the conversion of the Series A Shares, but does not include the shares of Common Stock for all accrued and unpaid dividends through the date of conversion. |
3. These securities are owned directly by Birchmere Ventures III TSIB LP. BV3 LLC is the general partner of BV3 Management LP, which is the general partner of Birchmere Ventures III TSIB LP. BV3 LLC and BV3 Management LP disclaim beneficial ownership in these securities to the extent it exceeds their pecuniary interest therein. |
4. The shares of Series B Convertible Preferred Stock (the "Series B Shares"), including all accrued and unpaid dividends thereon, will convert automatically into Common Stock on a 1-for-8.0149 basis upon the closing of the Issuer's initial public offering, and have no expiration date. |
5. Reflects the conversion of the Series B Shares, but does not include the shares of Common Stock for all accrued and unpaid dividends through the date of conversion. |
6. The Warrant to Purchase Series B Convertible Preferred Stock will convert automatically into a warrant to purchase 2,439 shares of Common Stock upon the closing of the Issuer's initial public offering. |
7. Reflects the automatic conversion of the Convertible Promissory Notes into Common Stock upon the closing of the Issuer's initial public offering, but does not include the shares of Common Stock for all accrued and unpaid interest through the date of conversion. |
/s/ Gary Glausser, Managing Member | 08/05/2010 | |
** Signature of Reporting Person | Date | |
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | ||
* If the form is filed by more than one reporting person, see Instruction 5 (b)(v). | ||
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). | ||
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. | ||
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. |