FORM 4 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940 |
|
|||||||||||||||
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). |
1. Name and Address of Reporting Person*
(Street)
|
2. Issuer Name and Ticker or Trading Symbol
Carbylan Therapeutics, Inc. [ CBYL ] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
|
||||||||||||||||||||||||
3. Date of Earliest Transaction
(Month/Day/Year) 04/14/2015 | ||||||||||||||||||||||||||
4. If Amendment, Date of Original Filed
(Month/Day/Year) |
6. Individual or Joint/Group Filing (Check Applicable Line)
|
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|
1. Title of Security (Instr. 3) | 2. Transaction Date (Month/Day/Year) | 2A. Deemed Execution Date, if any (Month/Day/Year) | 3. Transaction Code (Instr. 8) | 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) | 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) | 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 7. Nature of Indirect Beneficial Ownership (Instr. 4) | |||
Code | V | Amount | (A) or (D) | Price | ||||||
Common Stock | 04/14/2015 | C | 2,476,452 | A | (1) | 2,476,452 | I | See Footnote(2) | ||
Common Stock | 04/14/2015 | C | 18,142 | A | (1) | 2,494,594 | I | See Footnote(3) | ||
Common Stock | 04/14/2015 | C | 387,960 | A | (4) | 2,882,554 | I | See Footnote(2) | ||
Common Stock | 04/14/2015 | C | 2,842 | A | (4) | 2,885,396 | I | See Footnote(3) | ||
Common Stock | 04/14/2015 | C | 304,438 | A | (5) | 3,189,834 | I | See Footnote(2) | ||
Common Stock | 04/14/2015 | C | 2,230 | A | (5) | 3,192,064 | I | See Footnote(3) | ||
Common Stock | 04/14/2015 | P | 1,005,136 | A | $5 | 4,197,200 | I | See Footnote(2) | ||
Common Stock | 04/14/2015 | P | 7,364 | A | $5 | 4,204,564 | I | See Footnote(3) |
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
1. Title of Derivative Security (Instr. 3) | 2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) | 6. Date Exercisable and Expiration Date (Month/Day/Year) | 7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4) | 8. Price of Derivative Security (Instr. 5) | 9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) | 10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 11. Nature of Indirect Beneficial Ownership (Instr. 4) | ||||
Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||||||
Series B Convertible Preferred Stock | (1) | 04/14/2015 | C | 2,476,452 | (1) | (1) | Common Stock | 2,476,452 | (1) | 0 | I | See Footnote(2) | |||
Series B Convertible Preferred Stock | (1) | 04/14/2015 | C | 18,142 | (1) | (1) | Common Stock | 18,142 | (1) | 0 | I | See Footnote(3) | |||
Convertible Promissory Note | (4) | 04/14/2015 | C | 387,960 | (4) | (4) | Common Stock | 387,960 | (4) | 0 | I | See Footnote(2) | |||
Convertible Promissory Note | (4) | 04/14/2015 | C | 2,842 | (4) | (4) | Common Stock | 2,842 | (4) | 0 | I | See Footnote(3) | |||
Convertible Promissory Note | (5) | 04/14/2015 | C | 304,438 | (5) | (5) | Common Stock | 304,438 | (5) | 0 | I | See Footnote(2) | |||
Convertible Promissory Note | (5) | 04/14/2015 | C | 2,230 | (5) | (5) | Common Stock | 2,230 | (5) | 0 | I | See Footnote(3) |
Explanation of Responses: |
1. Upon the closing of the Issuer's initial public offering, each share of Series B Convertible Preferred Stock automatically converted into Common Stock on a one for one basis without payment or further consideration, and has no expiration date. |
2. The reported shares are held directly by Vivo Ventures Fund VI, L.P. ("VIF"). Vivo Ventures VI, LLC ("Vivo LLC") is the general partner of VIF. As such, Vivo LLC may be deemed to be the beneficial owner of the shares held directly by VIF. The managers of Vivo LLC include Frank Kung, Edgar Engleman, and Albert Cha. Accordingly, each Frank Kung, Edgar Engleman and Albert Cha may be deemed to be the beneficial owner of the shares held directly by VIF. Each of Vivo LLC, Frank Kung, Edgar Engleman and Albert Cha disclaims beneficial ownership of the securities held by VIF, except to the extent of such individual's or entity's pecuniary interests in the securities. |
3. The reported shares are held directly by Vivo Ventures VI Affiliates Fund, L.P. ("VIAF"). Vivo Ventures VI, LLC ("Vivo LLC") is the general partner of VIAF. As such, Vivo LLC may be deemed to be the beneficial owner of the shares held directly by VIAF. The managers of Vivo LLC include Frank Kung, Edgar Engleman, and Albert Cha. Accordingly, each Frank Kung, Edgar Engleman and Albert Cha may be deemed to be the beneficial owner of the shares held directly by VIAF. Each of Vivo LLC, Frank Kung, Edgar Engleman and Albert Cha disclaims beneficial ownership of the securities held by VIAF, except to the extent of such individual's or entity's pecuniary interests in the securities. |
4. The Convertible Promissory Note is convertible into the number of shares of the Issuer's Common Stock equal to the quotient obtained by dividing the entire principal amount and 184 days of accrued interest on the Convertible Promissory Note by 80% of the initial public offering price of $5.00 per share of the Issuer's Common Stock, automatically upon the closing of the Issuer's initial public offering, and has no expiration date. |
5. The Convertible Promissory Note is convertible into the number of shares of the Issuer's Common Stock equal to the quotient obtained by dividing the entire principal amount and 41 days of accrued interest on the Convertible Promissory Note by 80% of the initial public offering price of $5.00 per share of the Issuer's Common Stock, automatically upon the closing of the Issuer's initial public offering, and has no expiration date. |
Remarks: |
By: /s/ David J. Saul, Attorney-in-Fact | 04/14/2015 | |
** 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 4 (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. | ||
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. |