SEC Form 3
FORM 3 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES

Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934
or Section 30(h) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person*
Prokupets Elena

(Last) (First) (Middle)
C/O C4 THERAPEUTICS, INC.
490 ARSENAL WAY, SUITE 200

(Street)
WATERTOWN MA 02472

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
10/01/2020
3. Issuer Name and Ticker or Trading Symbol
C4 Therapeutics, Inc. [ CCCC ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director 10% Owner
Officer (give title below) Other (specify below)
5. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Beneficially Owned
1. Title of Security (Instr. 4) 2. Amount of Securities Beneficially Owned (Instr. 4) 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 4. Nature of Indirect Beneficial Ownership (Instr. 5)
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 4) 2. Date Exercisable and Expiration Date (Month/Day/Year) 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) 4. Conversion or Exercise Price of Derivative Security 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 6. Nature of Indirect Beneficial Ownership (Instr. 5)
Date Exercisable Expiration Date Title Amount or Number of Shares
Series A Preferred Stock (1) (1) Common Stock 118,574 (1) I By Spouse
Series A Preferred Stock (1) (1) Common Stock 592,873 (1) I By ERP Business Holdings, LP(2)
Stock Option (Right to Buy) (3) 07/12/2026 Common Stock 8,561 $2.11 D
Explanation of Responses:
1. Shares of Series A Preferred Stock and Series B Preferred Stock are convertible into Common Stock on a 8.4335-to-one basis into the aggregate number of shares of Common Stock shown in Column 3 at any time at the holder's election, and automatically upon the closing of the Issuer's initial public offering without payment or further consideration. The shares have no expiration date.
2. Shares held by ERP Business Holdings, L.P. The Reporting Person disclaims beneficial ownership of these shares except to the extent of her pecuniary interest therein.
3. 12.5% of this option vested and became exercisable on December 31, 2016, with the remainder vesting in 28 equal quarterly installments thereafter.
Remarks:
Exhibit 24 - Power of Attorney
/s/ Jolie M. Siegel, Attorney-in-Fact 10/01/2020
** Signature of Reporting Person Date
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
* If the form is filed by more than one reporting person, see Instruction 5 (b)(v).
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure.
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