0001567619-20-020931.txt : 20201210 0001567619-20-020931.hdr.sgml : 20201210 20201210201417 ACCESSION NUMBER: 0001567619-20-020931 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 2 CONFORMED PERIOD OF REPORT: 20201210 FILED AS OF DATE: 20201210 DATE AS OF CHANGE: 20201210 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Miller-Rich Nancy CENTRAL INDEX KEY: 0001735084 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39782 FILM NUMBER: 201381936 MAIL ADDRESS: STREET 1: C/O INTERCEPT PHARMACEUTICALS, INC. STREET 2: 10 HUDSON YARDS, 37TH FL CITY: NEW YORK STATE: NY ZIP: 10001 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: 4D Molecular Therapeutics Inc. CENTRAL INDEX KEY: 0001650648 STANDARD INDUSTRIAL CLASSIFICATION: BIOLOGICAL PRODUCTS (NO DIAGNOSTIC SUBSTANCES) [2836] IRS NUMBER: 473506994 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 5858 HORTON STREET #455 CITY: EMERYVILLE STATE: CA ZIP: 94608 BUSINESS PHONE: 5105052680 MAIL ADDRESS: STREET 1: 5858 HORTON STREET #455 CITY: EMERYVILLE STATE: CA ZIP: 94608 FORMER COMPANY: FORMER CONFORMED NAME: 4D Molecular Therapeutics Inc DATE OF NAME CHANGE: 20150811 3 1 doc1.xml FORM 3 X0206 3 2020-12-10 0 0001650648 4D Molecular Therapeutics Inc. FDMT 0001735084 Miller-Rich Nancy C/O 4D MOLECULAR THERAPEUTICS INC. 5858 HORTON STREET #455 EMERYVILLE CA 94608 1 0 0 0 Stock Option (Right to Buy) 18.66 2030-11-11 Common Stock 45000 D One-third of the shares subject to the option vest on the first anniversary measured from November 12, 2020 (the "Vesting Commencement Date"), and 1/36th of the total number of shares vest in twenty-four (24) successive and equal monthly installments thereafter, such that 100% of the shares subject to the option will be fully vested and exercisable on the third anniversary of the Vesting Commencement Date. /s/ August J. Moretti, Attorney-in-Fact for Nancy Miller-Rich 2020-12-10 EX-24 2 poa_rich.htm
4D Molecular Therapeutics, Inc.

Power of Attorney

Know all by these presents, that the undersigned hereby constitutes and appoints each of (i) the Chief Executive Officer of 4D Molecular Therapeutics, Inc., a Delaware corporation (the “Company”), who is currently David Kirn, M.D. and (ii) the Company’s Chief Financial Officer, who is August J. Moretti, and their respective successors (including anyone serving in such capacities on an interim or acting basis), signing singly, with full powers of substitution, as the undersigned’s true and lawful attorney-in-fact to:
1.
prepare, execute in the undersigned’s name and on the undersigned’s behalf, and submit to the U.S. Securities and Exchange Commission (the “SEC”) a Form ID, including amendments thereto, and any other documents necessary or appropriate to obtain codes and passwords enabling the undersigned to make electronic filings with the SEC of reports required by Section 16(a) of the Securities Exchange Act of 1934 or any rule or regulation of the SEC;
2.
execute for and on behalf of the undersigned, in the undersigned’s capacity as an officer and/or director of the Company, Forms 3, 4, and 5 and any amendments thereto in accordance with Section 16(a) of the Securities Exchange Act of 1934 and the rules thereunder;
3.
do and perform any and all acts for and on behalf of the undersigned which may be necessary or desirable to complete and execute any such Form 3, 4, or 5, complete and execute any amendment or amendments thereto, and timely file such form with the SEC and any stock exchange or similar authority; and
4.
take any other action of any type whatsoever in connection with the foregoing which, in the opinion of such attorney-in-fact, may be of benefit to, in the best interest of, or legally required by, the undersigned, it being understood that the documents executed by such attorney-in-fact on behalf of the undersigned pursuant to this Power of Attorney shall be in such form and shall contain such terms and conditions as such attorney-in-fact may approve in such attorney-in-fact’s discretion.
The undersigned hereby grants to each such attorney-in-fact full power and authority to do and perform any and every act and thing whatsoever requisite, necessary, or proper to be done in the exercise of any of the rights and powers herein granted, as fully to all intents and purposes as the undersigned might or could do if personally present, with full power of substitution or revocation, hereby ratifying and confirming all that such attorney-in-fact, or such attorney-in-fact’s substitute or substitutes, shall lawfully do or cause to be done by virtue of this power of attorney and the rights and powers herein granted. The undersigned acknowledges that the foregoing attorneys-in-fact, in serving in such capacity at the request of the undersigned, are not assuming, nor is the Company assuming, any of the undersigned’s responsibilities to comply with Section 16 of the Securities Exchange Act of 1934.
This Power of Attorney shall remain in full force and effect until the undersigned is no longer required to file Forms 3, 4, and 5 with respect to the undersigned’s holdings of and transactions in securities issued by the Company, unless earlier revoked by the undersigned in a signed writing delivered to the foregoing attorneys-in-fact.
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be executed as of this 10th  day of December, 2020.

/s/ Nancy Miller-Rich  
Nancy Miller-Rich