0000899243-18-028099.txt : 20181102 0000899243-18-028099.hdr.sgml : 20181102 20181102194023 ACCESSION NUMBER: 0000899243-18-028099 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: Amble Erik CENTRAL INDEX KEY: 0001756337 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38721 FILM NUMBER: 181158471 MAIL ADDRESS: STREET 1: 26 TECHNOLOGY DRIVE CITY: IRVINE STATE: CA ZIP: 92618 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 0 0001603756 Axonics Modulation Technologies, Inc. AXNX 0001756337 Amble Erik 26 TECHNOLOGY DRIVE IRVINE CA 92618 1 0 0 1 Former 10% Owner Common Stock 2018-11-02 4 C 0 451738 A 451738 I By NeoMed Innovation V, L.P. Common Stock 2018-11-02 4 C 0 455610 A 907348 I By NeoMed Innovation V, L.P. Common Stock 2018-11-02 4 C 0 243750 A 1151098 I By NeoMed Innovation V, L.P. Common Stock 2018-11-02 4 C 0 369786 A 1520884 I By NeoMed Innovation V, L.P. Series A Preferred Stock 2018-11-02 4 C 0 195000 0.00 D Common Stock 451738 0 I By NeoMed Innovation V, L.P. Series B-1 Preferred Stock 2018-11-02 4 C 0 379675 0.00 D Common Stock 455610 0 I By NeoMed Innovation V, L.P. Series B-2 Preferred Stock 2018-11-02 4 C 0 203125 0.00 D Common Stock 243750 0 I By NeoMed Innovation V, L.P. Series C Preferred Stock 2018-11-02 4 C 0 308155 0.00 D Common Stock 369786 0 I By NeoMed Innovation V, L.P. 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 NeoMed Innovation V, L.P. ("NeoMed"). NeoMed Innovation V Limited is the general partner of NeoMed and has voting and dispositive power over the shares held by NeoMed. Erik Amble, Ph.D., who is a member of the Issuer's board of directors, is a director of NeoMed Innovation V Limited, and may be deemed to have voting and dispositive power over the shares held by NeoMed. Mr. Amble disclaims beneficial ownership of these securities and this report shall not be deemed an admission that Mr. Amble is the beneficial owner of such securities for purposes of Section 16 or for any other purpose, except to the extent of his respective pecuniary interest therein. 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. 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 C preferred stock automatically converted into 1.2 shares of the Issuer's common stock. The C preferred stock had no expiration date. /s/ Michael V. Williamson, as Attorney-in-Fact for Erik Amble, Ph.D. 2018-11-02