0001104659-18-031870.txt : 20180509 0001104659-18-031870.hdr.sgml : 20180509 20180509212242 ACCESSION NUMBER: 0001104659-18-031870 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20180507 FILED AS OF DATE: 20180509 DATE AS OF CHANGE: 20180509 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Stack Richard S. CENTRAL INDEX KEY: 0001584403 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38468 FILM NUMBER: 18820241 MAIL ADDRESS: STREET 1: 3284 ALPINE ROAD CITY: PORTOLA VALLEY STATE: CA ZIP: 94028 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Starling William N JR CENTRAL INDEX KEY: 0001324130 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38468 FILM NUMBER: 18820240 MAIL ADDRESS: STREET 1: 2300 BUCKSKIN ROAD CITY: POCATELLO STATE: ID ZIP: 83201 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: SYNERGY LIFE SCIENCE PARTNERS L P CENTRAL INDEX KEY: 0001384771 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38468 FILM NUMBER: 18820243 BUSINESS ADDRESS: STREET 1: 3282 ALPINE RD CITY: PORTOLA VALLEY STATE: CA ZIP: 94028 BUSINESS PHONE: 714-815-9099 MAIL ADDRESS: STREET 1: 3282 ALPINE RD CITY: PORTOLA VALLEY STATE: CA ZIP: 94028 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Synergy Venture Partners, LLC CENTRAL INDEX KEY: 0001584405 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38468 FILM NUMBER: 18820242 BUSINESS ADDRESS: STREET 1: 3284 ALPINE ROAD CITY: PORTOLA VALLEY STATE: CA ZIP: 94028 BUSINESS PHONE: (650) 854-9171 MAIL ADDRESS: STREET 1: 3284 ALPINE ROAD CITY: PORTOLA VALLEY STATE: CA ZIP: 94028 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Inspire Medical Systems, Inc. CENTRAL INDEX KEY: 0001609550 STANDARD INDUSTRIAL CLASSIFICATION: SURGICAL & MEDICAL INSTRUMENTS & APPARATUS [3841] IRS NUMBER: 261377674 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 9700 63RD AVENUE N STREET 2: SUITE 200 CITY: MAPLE GROVE STATE: X1 ZIP: 55369 BUSINESS PHONE: 763-205-7970 MAIL ADDRESS: STREET 1: 9700 63RD AVENUE N STREET 2: SUITE 200 CITY: MAPLE GROVE STATE: X1 ZIP: 55369 4 1 a4.xml 4 X0306 4 2018-05-07 1 0001609550 Inspire Medical Systems, Inc. INSP 0001384771 SYNERGY LIFE SCIENCE PARTNERS L P 1350 BAYSHORE HIGHWAY, SUITE 920 BURLINGAME CA 94010 0 0 1 0 0001584405 Synergy Venture Partners, LLC 1350 BAYSHORE HIGHWAY, SUITE 920 BURLINGAME CA 94010 0 0 1 0 0001584403 Stack Richard S. 1350 BAYSHORE HIGHWAY, SUITE 920 BURLINGAME CA 94010 0 0 1 0 0001324130 Starling William N JR 1350 BAYSHORE HIGHWAY, SUITE 920 BURLINGAME CA 94010 0 0 1 0 Common Stock 2018-05-07 4 C 0 741494 A 741494 D Common Stock 2018-05-07 4 C 0 419663 A 1161157 D Common Stock 2018-05-07 4 C 0 195465 A 1356622 D Common Stock 2018-05-07 4 C 0 272391 A 1629013 D Common Stock 2018-05-07 4 C 0 466494 A 2095507 D Series B Convertible Preferred Stock 2018-05-07 4 C 0 3998154 0 D Common Stock 741494 0 D Series C Convertible Preferred Stock 2018-05-07 4 C 0 2790760 0 D Common Stock 419663 0 D Series D Convertible Preferred Stock 2018-05-07 4 C 0 1299847 0 D Common Stock 195465 0 D Series E Convertible Preferred Stock 2018-05-07 4 C 0 1576336 0 D Common Stock 272391 0 D Series F Convertible Preferred Stock 2018-05-07 4 C 0 3102190 0 D Common Stock 466494 0 D Shares of Series B Convertible Preferred Stock automatically converted into shares of the Issuer's Common Stock at a 1-for-0.1855 conversion rate immediately prior to the closing of the Issuer's initial public offering ("IPO") for no additional consideration (subject to the payment of cash in lieu of any fractional shares in accordance with the Issuer's Sixth Amended and Restated Certificate of Incorporation (as amended, the "Certificate of Incorporation")). These shares had no expiration date. Shares of Series C, Series D and Series F Convertible Preferred Stock automatically converted into shares of the Issuer's Common Stock at a 1-for-0.1504 conversion rate immediately prior to the closing of the Issuer's IPO for no additional consideration (subject to the payment of cash in lieu of any fractional shares in accordance with the Issuer's Certificate of Incorporation). These shares had no expiration date. Shares of Series E Convertible Preferred Stock automatically converted into shares of the Issuer's Common Stock at a 1-for-0.1728 conversion rate immediately prior to the closing of the Issuer's IPO for no additional consideration (subject to the payment of cash in lieu of any fractional shares in accordance with the Issuer's Certificate of Incorporation). These shares had no expiration date. Synergy Venture Partners, LLC ("SVP LLC") serves as the sole General Partner of Synergy Life Science Partners, LP ("Synergy"). As such, SVP LLC possesses sole voting and investment control over the securities owned by Synergy, and may be deemed to have indirect beneficial ownership of the securities held by Synergy. SVP LLC, however, owns no securities of the Issuer directly. Mudit K. Jain, a director of the Issuer, and each of Messrs. Stack and Starling are Managers of SVP LLC and share voting and dispositive power over the shares held by Synergy. Such persons and entities disclaim beneficial ownership of the shares held by Synergy except to the extent of his or its proportionate pecuniary interest therein. /s/ Richard Buchholz, as Attorney-in-Fact for Synergy Life Science Partners, LP 2018-05-09 /s/ Richard Buchholz, as Attorney-in-Fact for Synergy Venture Partners, LLC 2018-05-09 /s/ Richard Buchholz, as Attorney-in-Fact for Richard S. Stack 2018-05-09 /s/ Richard Buchholz, as Attorney-in-Fact for William N. Starling, Jr. 2018-05-09