0001570562-23-000092.txt : 20230815 0001570562-23-000092.hdr.sgml : 20230815 20230815163251 ACCESSION NUMBER: 0001570562-23-000092 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20230811 FILED AS OF DATE: 20230815 DATE AS OF CHANGE: 20230815 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: BLANK SIMONE CENTRAL INDEX KEY: 0001366840 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38381 FILM NUMBER: 231175339 MAIL ADDRESS: STREET 1: C/O SIRONA, WASSERFELDSTRASSE 30 A-5020 CITY: SALZBURG STATE: C4 ZIP: 5020 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Evolus, Inc. CENTRAL INDEX KEY: 0001570562 STANDARD INDUSTRIAL CLASSIFICATION: PHARMACEUTICAL PREPARATIONS [2834] IRS NUMBER: 461385614 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 520 NEWPORT CENTER DRIVE STREET 2: SUITE 1200 CITY: NEWPORT BEACH STATE: CA ZIP: 92660 BUSINESS PHONE: (949) 284-4555 MAIL ADDRESS: STREET 1: 520 NEWPORT CENTER DRIVE STREET 2: SUITE 1200 CITY: NEWPORT BEACH STATE: CA ZIP: 92660 4 1 wk-form4_1692131560.xml FORM 4 X0508 4 2023-08-11 0 0001570562 Evolus, Inc. EOLS 0001366840 BLANK SIMONE 520 NEWPORT CENTER DR. SUITE 1200 NEWPORT BEACH CA 92660 1 0 0 0 0 Common Stock 2023-08-11 4 J 0 109 0 A 63283 D Common Stock 2023-08-11 4 J 0 115206 0 A 482783 I See Footnote Pro rata distribution from Alphaeon 1, LLC of which the reporting person is a non-managing member. Represents shares held by Dental Innovations Apus Investment BV ("DIAI") and may be deemed beneficially owned by the Reporting Person as the sole beneficial owner of DIAI. /s/ Jeffrey J. Plumer, as attorney-in-fact for Simone Blank 2023-08-15