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