0001209191-20-031476.txt : 20200521 0001209191-20-031476.hdr.sgml : 20200521 20200521184626 ACCESSION NUMBER: 0001209191-20-031476 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 2 CONFORMED PERIOD OF REPORT: 20200521 FILED AS OF DATE: 20200521 DATE AS OF CHANGE: 20200521 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Gilde Healthcare Holding B.V. CENTRAL INDEX KEY: 0001420106 STATE OF INCORPORATION: P7 FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39293 FILM NUMBER: 20903281 BUSINESS ADDRESS: STREET 1: NEWTONLAAN 91 STREET 2: PO BOX 85067 CITY: 3508 UTRECHT STATE: P7 ZIP: AB BUSINESS PHONE: 31(0)30-2192549 MAIL ADDRESS: STREET 1: NEWTONLAAN 91 STREET 2: PO BOX 85067 CITY: 3508 UTRECHT STATE: P7 ZIP: AB REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Gilde Healthcare IV Management B.V. CENTRAL INDEX KEY: 0001757508 STATE OF INCORPORATION: P7 FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39293 FILM NUMBER: 20903282 BUSINESS ADDRESS: STREET 1: NEWTONLAAN 91 CITY: UTRECHT STATE: P7 ZIP: 3584 BP BUSINESS PHONE: 949-396-6322 MAIL ADDRESS: STREET 1: NEWTONLAAN 91 CITY: UTRECHT STATE: P7 ZIP: 3584 BP REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Cooperatieve Gilde Healthcare IV U.A. CENTRAL INDEX KEY: 0001756335 STATE OF INCORPORATION: P7 FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39293 FILM NUMBER: 20903283 BUSINESS ADDRESS: STREET 1: NEWTONLANN 51 CITY: UTRECHT STATE: P7 ZIP: 3508AB BUSINESS PHONE: 949-396-6322 MAIL ADDRESS: STREET 1: NEWTONLANN 51 CITY: UTRECHT STATE: P7 ZIP: 3508AB ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Inari Medical, Inc. CENTRAL INDEX KEY: 0001531048 STANDARD INDUSTRIAL CLASSIFICATION: SURGICAL & MEDICAL INSTRUMENTS & APPARATUS [3841] IRS NUMBER: 452902923 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 9 PARKER, SUITE 100 CITY: IRVINE STATE: CA ZIP: 92618 BUSINESS PHONE: 949-923-4747 MAIL ADDRESS: STREET 1: 9 PARKER, SUITE 100 CITY: IRVINE STATE: CA ZIP: 92618 FORMER COMPANY: FORMER CONFORMED NAME: Inceptus Newco1 Inc. DATE OF NAME CHANGE: 20110923 3 1 doc3.xml FORM 3 SUBMISSION X0206 3 2020-05-21 0 0001531048 Inari Medical, Inc. NARI 0001756335 Cooperatieve Gilde Healthcare IV U.A. NEWTONLAAN 91 3584 BP UTRECHT P7 NETHERLANDS 0 0 1 0 0001757508 Gilde Healthcare IV Management B.V. NEWTONLAAN 91 3584 BP UTRECHT P7 NETHERLANDS 0 0 1 0 0001420106 Gilde Healthcare Holding B.V. NEWTONLAAN 91 3584 BP UTRECHT P7 NETHERLANDS 0 0 1 0 Series C Preferred Stock Common Stock 7599350 I See footnote Each share of the Issuer's preferred stock is convertible on a one-to-one basis into shares of the Issuer's common stock at the holder's election and has no expiration date. The preferred stock will automatically convert into common stock upon the closing of the Issuer's initial public offering. All securities reported are held of record by Cooperatieve Gilde Healthcare IV U.A. ("Gilde"). Gilde is managed by Gilde Healthcare IV Management B.V. ("Management"). Management is owned by Gilde Healthcare Holding B.V. ("Holding"). Each of Management and Holding may be deemed to have voting, investment and dispositive power with respect to the securities held by Gilde. Each of Management and Holding disclaims beneficial ownership of these securities and this report shall not be deemed an admission that any of them is the beneficial owner of such securities, except to the extent of their respective pecuniary interests therein. Exhibit 24 - Power of Attorney. Cooperatieve Gilde Healthcare IV U.A., By: /s/ Mitchell Hill, Attorney-in-Fact 2020-05-21 Gilde Healthcare IV Management B.V., By: /s/ Mitchell, Attorney-in-Fact 2020-05-21 Gilde Healthcare HOlding B.V., By: /s/ Mitchell Hill, Attorney-in-Fact 2020-05-21 EX-24.3_917061 2 poa.txt POA DOCUMENT POWER OF ATTORNEY With respect to holdings of and transactions in securities issued by Inari Medical, Inc. (the "Company"), the undersigned hereby constitutes and appoints the individual or individuals named on Schedule A attached hereto and as may be amended from time to time, or any of them signing singly, with full power of substitution and resubstitution, to act as the undersigned's true and lawful attorney-in-fact to: 1. prepare, execute in the undersigned's name and on the undersigned's behalf, and submit to the United States Securities and Exchange Commission (the "SEC") a Form ID, including amendments thereto, and any other documents necessary or appropriate to obtain and/or regenerate codes and passwords enabling the undersigned to make electronic filings with the SEC of reports required by Section 16(a) of the Securities Exchange Act of 1934, as amended, or any rule or regulation of the SEC; 2. execute for and on behalf of the undersigned, Forms 3, 4, and 5 in accordance with Section 16 of the Securities Exchange Act of 1934, as amended, and the rules thereunder; 3. do and perform any and all acts for and on behalf of the undersigned which may be necessary or desirable to complete and execute any such Form 3, 4, or 5, complete and execute any amendment or amendments thereto, and timely file such form with the SEC and any stock exchange or similar authority; and 4. take any other action of any type whatsoever in connection with the foregoing which, in the opinion of such attorney-in-fact, may be of benefit to, in the best interest of, or legally required by, the undersigned, it being understood that the documents executed by such attorney-in-fact on behalf of the undersigned pursuant to this Power of Attorney shall be in such form and shall contain such terms and conditions as such attorney-in-fact may approve in such attorney-in-fact's discretion. The undersigned hereby grants to each such attorney-in-fact full power and authority to do and perform any and every act and thing whatsoever requisite, necessary, or proper to be done in the exercise of any of the rights and powers herein granted, as fully to all intents and purposes as the undersigned might or could do if personally present, with full power of substitution and resubstitution or revocation, hereby ratifying and confirming all that such attorney-in-fact, or such attorneys-in-fact substitute or substitutes, shall lawfully do or cause to be done by virtue of this Power of Attorney and the rights and powers herein granted. The undersigned acknowledges that the foregoing attorneys-in-fact, in serving in such capacity at the request of the undersigned, are not assuming, nor is the Company assuming, any of the undersigned's responsibilities to comply with Section 16 of the Securities Exchange Act of 1934, as amended. This Power of Attorney shall remain in full force and effect until the undersigned is no longer required to file Forms 3, 4, and 5 with respect to the undersigned's holdings of and transactions in securities issued by the Company, unless earlier revoked by the undersigned in a signed writing delivered to the foregoing attorneys-in-fact. IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be executed as of this 7th day of May, 2020. Cooperatieve Gilde Healthcare IV U.A. By: /s/ Marc Perret Name: Marc Perret Title: Managing Director Gilde Healthcare IV Management B.V. By: /s/ Marc Perret Name: Marc Perret Title: Managing Director Gilde Healthcare Holding B.V. By: /s/ Marc Perret Name: Marc Perret Title: Managing Director Schedule A Individual Appointed as Attorney-in-Fact with Full Power of Substitution and Resubstitution 1. William Hoffman 2. Mitchell Hill