0000899243-18-028080.txt : 20181102 0000899243-18-028080.hdr.sgml : 20181102 20181102192626 ACCESSION NUMBER: 0000899243-18-028080 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20181102 FILED AS OF DATE: 20181102 DATE AS OF CHANGE: 20181102 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Kuang Zhong CENTRAL INDEX KEY: 0001757506 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38721 FILM NUMBER: 181158441 MAIL ADDRESS: STREET 1: ROOM 3005, NO. 82 MINZU ROAD CITY: NANNING, GUANGXI STATE: F4 ZIP: 530022 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Zac & Cloud Holdings LTD CENTRAL INDEX KEY: 0001757405 STATE OF INCORPORATION: F4 FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38721 FILM NUMBER: 181158442 BUSINESS ADDRESS: STREET 1: ROOM 3005, NO. 82 MINZU ROAD CITY: NANNING, GUANGXI STATE: F4 ZIP: 530022 BUSINESS PHONE: 949-396-6322 MAIL ADDRESS: STREET 1: ROOM 3005, NO. 82 MINZU ROAD CITY: NANNING, GUANGXI STATE: F4 ZIP: 530022 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Axonics Modulation Technologies, Inc. CENTRAL INDEX KEY: 0001603756 STANDARD INDUSTRIAL CLASSIFICATION: SURGICAL & MEDICAL INSTRUMENTS & APPARATUS [3841] IRS NUMBER: 454744083 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 26 TECHNOLOGY DRIVE CITY: IRVINE STATE: CA ZIP: 92618 BUSINESS PHONE: 949-396-6322 MAIL ADDRESS: STREET 1: 26 TECHNOLOGY DRIVE CITY: IRVINE STATE: CA ZIP: 92618 4 1 doc4.xml FORM 4 SUBMISSION X0306 4 2018-11-02 1 0001603756 Axonics Modulation Technologies, Inc. AXNX 0001757506 Kuang Zhong ROOM 3005 NANHU JIAHECHENG NO. 82 MINZU ROAD NANNING 530022 0 0 0 1 Former 10% Owner 0001757405 Zac & Cloud Holdings LTD ROOM 3005 NANHU JIAHECHENG NO. 82 MINZU ROAD NANNING 530022 0 0 0 1 Former 10% Owner Common Stock 2018-11-02 4 C 0 347491 A 347491 I Zac and Cloud Holdings Ltd. Common Stock 2018-11-02 4 C 0 349862 A 697353 I Zac and Cloud Holdings Ltd. Common Stock 2018-11-02 4 C 0 187500 A 884853 I Zac and Cloud Holdings Ltd. Series A Preferred Stock 2018-11-02 4 C 0 150000 0.00 D Common Stock 347491 0 I Zac and Cloud Holdings Ltd. Series B-1 Preferred Stock 2018-11-02 4 C 0 291551 0.00 D Common Stock 349862 0 I Zac and Cloud Holdings Ltd. Series B-2 Preferred Stock 2018-11-02 4 C 0 156250 0.00 D Common Stock 187500 0 I Zac and Cloud Holdings Ltd. Reflects a 1.2-for-1 forward stock split of the Issuer's common stock effected on October 18, 2018. Effective upon the closing of the Issuer's initial public offering of its common stock under the Securities Act of 1933, as amended, each share of Series A preferred stock automatically converted into 2.31660 shares of the Issuer's common stock. The A preferred stock had no expiration date. The shares are held of record by Zac and Cloud Holdings Ltd. ("Cloud"). Zhong Kuang is the sole-shareholder of Cloud and has voting and dispositive power over the shares held by Cloud. Effective upon the closing of the Issuer's initial public offering of its common stock under the Securities Act of 1933, as amended, each share of Series B-1 preferred stock automatically converted into 1.2 shares of the Issuer's common stock. The B-1 preferred stock had no expiration date. Effective upon the closing of the Issuer's initial public offering of its common stock under the Securities Act of 1933, as amended, each share of Series B-2 preferred stock automatically converted into 1.2 shares of the Issuer's common stock. The B-2 preferred stock had no expiration date. /s/ Zhong Kuang, on behalf of Zac and Cloud Holdings Ltd. 2018-11-02 /s/ Zhong Kuang 2018-11-02