0001225208-18-011385.txt : 20180703
0001225208-18-011385.hdr.sgml : 20180703
20180703194220
ACCESSION NUMBER: 0001225208-18-011385
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20180702
FILED AS OF DATE: 20180703
DATE AS OF CHANGE: 20180703
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Pullara Samuel J III
CENTRAL INDEX KEY: 0001561643
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-38554
FILM NUMBER: 18939140
MAIL ADDRESS:
STREET 1: 755 PAGE MILL ROAD, SUITE A-200
CITY: PALO ALTO
STATE: CA
ZIP: 94304
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: Forty Seven, Inc.
CENTRAL INDEX KEY: 0001667633
STANDARD INDUSTRIAL CLASSIFICATION: PHARMACEUTICAL PREPARATIONS [2834]
IRS NUMBER: 474065674
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
BUSINESS ADDRESS:
STREET 1: 1490 O'BRIEN DRIVE, SUITE A
CITY: MENLO PARK
STATE: CA
ZIP: 94025
BUSINESS PHONE: (650) 352-4150
MAIL ADDRESS:
STREET 1: 1490 O'BRIEN DRIVE, SUITE A
CITY: MENLO PARK
STATE: CA
ZIP: 94025
4
1
doc4.xml
X0306
4
2018-07-02
1
0001667633
Forty Seven, Inc.
FTSV
0001561643
Pullara Samuel J III
755 PAGE MILL ROAD, SUITE A-200
PALO ALTO
CA
94304-1005
1
Former 10% Holder
Common Stock
2018-07-02
4
C
0
1052146.0000
0
A
1052146.0000
I
By Ltd Partnership (SHV)
Common Stock
2018-07-02
4
C
0
945326.0000
0
A
1997472.0000
I
By Ltd Partnership (SHV)
Common Stock
2018-07-02
4
C
0
774165.0000
0
A
2771637.0000
I
By Ltd Partnership (SHV)
Common Stock
2018-07-02
4
P
0
134735.0000
16.0000
A
2906372.0000
I
By Ltd Partnership (SHV)
Common Stock
2018-07-02
4
C
0
2580.0000
0
A
2580.0000
I
By Profit Sharing Plan Trust
Common Stock
2018-07-02
4
C
0
14445.0000
0
A
14445.0000
I
By Trust
Common Stock
2018-07-02
4
C
0
14067.0000
0
A
28512.0000
I
By Trust
Common Stock
2018-07-02
4
C
0
11258.0000
0
A
39770.0000
I
By Trust
Common Stock
2018-07-02
4
P
0
2059.0000
16.0000
A
41829.0000
I
By Trust
Series A-1 Preferred Stock
2018-07-02
4
C
0
1052146.0000
D
Common Stock
1052146.0000
0.0000
I
By Ltd Partnership (SHV)
Series A-2 Preferred Stock
2018-07-02
4
C
0
774165.0000
D
Common Stock
774165.0000
0.0000
I
By Ltd Partnership (SHV)
Series B Preferred Stock
2018-07-02
4
C
0
945326.0000
D
Common Stock
945326.0000
0.0000
I
By Ltd Partnership (SHV)
Series A-1 Preferred Stock
2018-07-02
4
C
0
2580.0000
D
Common Stock
2580.0000
0.0000
I
By Profit Sharing Plan Trust
Series A-1 Preferred Stock
2018-07-02
4
C
0
11258.0000
D
Common Stock
11258.0000
0.0000
I
By Trust
Series A-2 Preferred Stock
2018-07-02
4
C
0
14067.0000
D
Common Stock
14067.0000
0.0000
I
By Trust
Series B Preferred Stock
2018-07-02
4
C
0
14445.0000
D
Common Stock
14445.0000
0.0000
I
By Trust
The issuer's preferred stock automatically converted into issuer's common stock on a one-to-one basis immediately upon the closing of the issuer's initial public offering and has no expiration date.
Shares held by Sutter Hill Ventures, a California Limited Partnership. The reporting person is a managing director and member of the management committee of the general partner of Sutter Hill Ventures, a California Limited Partnership. The reporting person disclaims beneficial ownership in these shares except as to the reporting person's pecuniary interest therein.
Shares held by the Sutter Hill Ventures, a California Limited Partnership Profit Sharing Plan, a retirement trust, for the benefit of the reporting person.
Shares held by a trust of which the reporting person is a trustee. The reporting person disclaims beneficial ownership in these shares except as to the reporting person's pecuniary interest therein.
/s/ Robert Yin, by power of attorney
2018-07-02