0001019687-14-000409.txt : 20140206 0001019687-14-000409.hdr.sgml : 20140206 20140206171012 ACCESSION NUMBER: 0001019687-14-000409 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20140205 FILED AS OF DATE: 20140206 DATE AS OF CHANGE: 20140206 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Eleven Biotherapeutics, Inc. CENTRAL INDEX KEY: 0001485003 STANDARD INDUSTRIAL CLASSIFICATION: PHARMACEUTICAL PREPARATIONS [2834] IRS NUMBER: 252025616 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 215 FIRST STREET STREET 2: SUITE 400 CITY: CAMBRIDGE STATE: MA ZIP: 02142 BUSINESS PHONE: 617-871-9911 MAIL ADDRESS: STREET 1: 215 FIRST STREET STREET 2: SUITE 400 CITY: CAMBRIDGE STATE: MA ZIP: 02142 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: JAFCO Super V3 Investment Limited Partnership CENTRAL INDEX KEY: 0001590442 STATE OF INCORPORATION: M0 FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-36296 FILM NUMBER: 14580971 BUSINESS ADDRESS: STREET 1: OTEMACHI FIRST SQUARE, WEST TOWER 11F STREET 2: 1-5-1 OTEMACHI CITY: CHIYODA-KU, TOKYO 100-0004 STATE: M0 ZIP: 100-0004 BUSINESS PHONE: 81-3-5223-7008 MAIL ADDRESS: STREET 1: OTEMACHI FIRST SQUARE, WEST TOWER 11F STREET 2: 1-5-1 OTEMACHI CITY: CHIYODA-KU, TOKYO 100-0004 STATE: M0 ZIP: 100-0004 3 1 jafco_frm3.xml FORM 3 X0206 3 2014-02-05 0 0001485003 Eleven Biotherapeutics, Inc. EBIO 0001590442 JAFCO Super V3 Investment Limited Partnership OTEMACHI FIRST SQUARE, WEST TOWER 11F CHIYODA-KU, TOKYO 100-0004 M0 100-0004 JAPAN 0 0 1 0 Series A Preferred Stock 0 Common Stock 1574803 D Series B Preferred Stock 0 Common Stock 232105 D Common Stock Warrant (right to purchase) 0.0635 Common Stock 61242 D Common Stock Warrant (right to purchase) 0.0635 Common Stock 39994 D The Series A Preferred Stock is convertible into Common Stock on an 6.35-for-one basis into the number of shares of Common Stock as shown in column 3 at any time at the holder's election, and automatically upon the closing of the Issuer's initial public offering, and has no expiration date. The Series B Preferred Stock is convertible into Common Stock on an 6.35-for-one basis into the number of shares of Common Stock as shown in column 3 at any time at the holder's election, and automatically upon the closing of the Issuer's initial public offering, and has no expiration date. The Warrant to purchase Common Stock as shown in column 3 is exercisable at any time at the holder's election prior to June 28, 2018, and automatically upon the closing of the Issuer's initial public offering. The Warrant to purchase Common Stock as shown in column 3 is exercisable at any time at the holder's election prior to December 6, 2018, and automatically upon the closing of the Issuer's initial public offering. /s/ Hironori Hozoji 2014-02-06