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