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