0000905718-21-001112.txt : 20210817 0000905718-21-001112.hdr.sgml : 20210817 20210817125109 ACCESSION NUMBER: 0000905718-21-001112 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20210817 FILED AS OF DATE: 20210817 DATE AS OF CHANGE: 20210817 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Bedoya-Toro Munera Maria E CENTRAL INDEX KEY: 0001400048 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-40739 FILM NUMBER: 211182042 MAIL ADDRESS: STREET 1: 10590 WEST OCEAN AIR DRIVE STREET 2: SUITE 200 CITY: SAN DIEGO STATE: CA ZIP: 92130 FORMER NAME: FORMER CONFORMED NAME: Bedoya-Toro Maria E DATE OF NAME CHANGE: 20070521 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Dermata Therapeutics, Inc. CENTRAL INDEX KEY: 0001853816 STANDARD INDUSTRIAL CLASSIFICATION: PHARMACEUTICAL PREPARATIONS [2834] IRS NUMBER: 000000000 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 3525 DEL MAR HEIGHTS RD., #332 CITY: SAN DIEGO STATE: CA ZIP: 92130 BUSINESS PHONE: (858)-223-0882 MAIL ADDRESS: STREET 1: 3525 DEL MAR HEIGHTS RD., #332 CITY: SAN DIEGO STATE: CA ZIP: 92130 4 1 dermata_fm4aug172021.xml X0306 4 2021-08-17 0 0001853816 Dermata Therapeutics, Inc. DRMA 0001400048 Bedoya-Toro Munera Maria E 3525 DEL MAR HEIGHTS RD., #332 SAN DIEGO CA 92130 0 1 0 0 Senior Vice President Common Stock 2021-08-17 4 C 0 9162 A 28674 I By Munera Family Trust Common Stock 2021-08-17 4 C 0 19512 A 48186 I By Munera Family Trust Common Stock 2021-08-17 4 C 0 4878 A 53064 I By Munera Family Trust Common Stock 2021-08-17 4 C 0 17421 A 70485 I By Munera Family Trust Common Stock 2021-08-17 4 C 0 13658 A 84143 I By Munera Family Trust Common Stock 30487 D Series 1d Preferred Stock 2021-08-17 4 C 0 61821 0 D Common Stock 9162 0 I By Munera Family Trust Series 1a Preferred Stock 2021-08-17 4 C 0 400000 0 D Common Stock 19512 0 I By Munera Family Trust Series 1b Preferred Stock 2021-08-17 4 C 0 100000 0 D Common Stock 4878 0 I By Munera Family Trust Series 1c Preferred Stock 2021-08-17 4 C 0 357142 0 D Common Stock 17421 0 I By Munera Family Trust Series 1 Preferred Stock 2021-08-17 4 C 0 280000 0 D Common Stock 13658 0 I By Munera Family Trust Series 1a Warrants 2021-08-17 4 C 0 100000 0 D 2016-11-15 2026-03-14 Common Stock 4878 0 I By Munera Family Trust Warrant to Purchase Common Stock 20.50 2021-08-17 4 C 0 4878 0 A 2016-11-15 2026-03-14 Common Stock 4878 4878 I By Munera Family Trust The Series 1d Preferred Stock automatically converted into Common Stock of the Issuer upon consummation of the Issuer's initial public offering (the "IPO"). The Series 1d Preferred Stock was convertible at any time and had no expiration date. The Series 1a Preferred Stock converted into Common Stock of the Issuer upon consummation of the IPO. The Series 1a Preferred Stock was convertible at any time and had no expiration date. The Series 1b Preferred Stock converted into Common Stock of the Issuer upon consummation of the IPO. The Series 1b Preferred Stock was convertible at any time and had no expiration date. The Series 1c Preferred Stock converted into Common Stock of the Issuer upon consummation of the IPO. The Series 1c Preferred Stock was convertible at any time and had no expiration date. The Series 1 Preferred Stock converted into Common Stock of the Issuer upon consummation of the IPO. The Series 1 Preferred Stock was convertible at any time and had no expiration date. The Series 1a Preferred Warrants converted into warrants to purchase Common Stock in connection with the IPO. Reporting Person disclaims beneficial ownership of these securities except to the extent of their pecuniary interest therein, and the inclusion of these shares in this report shall not be deemed an admission of beneficial ownership of all of the reported shares for purposes of Section 16 or for any other purpose. /s/ Gerald T. Proehl, Attorney-in-Fact 2021-08-17