0001104659-15-081133.txt : 20151124 0001104659-15-081133.hdr.sgml : 20151124 20151124162610 ACCESSION NUMBER: 0001104659-15-081133 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20151124 FILED AS OF DATE: 20151124 DATE AS OF CHANGE: 20151124 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Axsome Therapeutics, Inc. CENTRAL INDEX KEY: 0001579428 STANDARD INDUSTRIAL CLASSIFICATION: PHARMACEUTICAL PREPARATIONS [2834] IRS NUMBER: 454241907 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 45 ROCKEFELLER PLAZA, SUITE 2000 CITY: NEW YORK STATE: NY ZIP: 10111 BUSINESS PHONE: 212-203-5072 MAIL ADDRESS: STREET 1: 45 ROCKEFELLER PLAZA, SUITE 2000 CITY: NEW YORK STATE: NY ZIP: 10111 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Kaye Randall CENTRAL INDEX KEY: 0001350416 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-37635 FILM NUMBER: 151252991 MAIL ADDRESS: STREET 1: 11388 SORRENTO VALLEY ROAD STREET 2: STE. 200 CITY: SAN DIEGO STATE: CA ZIP: 92121 4 1 a4.xml 4 X0306 4 2015-11-24 0 0001579428 Axsome Therapeutics, Inc. AXSM 0001350416 Kaye Randall 25 BROADWAY, 9TH FLOOR NEW YORK NY 10004 0 1 0 0 Chief Medical Officer Common Stock 2015-11-24 4 C 0 5022 5.40 A 5022 D 8% Convertible Note 5.40 2015-11-24 4 A 0 5022 0 A 2024-11-03 Common Stock 5022 0 D Consists of an 8% Convertible Note with a principal balance of $25,000 and interest accrued through November 24, 2015 of $2,121. /s/ Constance Ames, Attorney-in-Fact 2015-11-24