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