Statement of Changes in Beneficial Ownership (4)
November 26 2021 - 1:31PM
Edgar (US Regulatory)
FORM 4
[ ]
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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3235-0287
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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
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PROEHL GERALD T |
2. Issuer Name and Ticker or Trading Symbol
Dermata Therapeutics, Inc.
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DRMA
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__X__ Director __X__ 10% Owner
__X__ Officer (give title below) _____ Other (specify below)
President, CEO and Chairman |
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(Last)
(First)
(Middle)
C/O DERMATA THERAPEUTICS, INC., 3525 DEL MAR HEIGHTS RD., #332 |
3. Date of Earliest Transaction
(MM/DD/YYYY)
11/23/2021 |
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(Street)
SAN DIEGO, CA 92130
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
_X
_ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security
(Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code
(Instr. 8)
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4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)
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7. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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Amount
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(A) or (D)
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Price
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| Common Stock | 11/23/2021 | | P | | 20000 | A | $2.40 | 59512 | D | |
| Common Stock | | | | | | | | 17857 | I | By Allison Taylor Proehl 2020 Irrevocable Trust (1) |
| Common Stock | | | | | | | | 8928 | I | By Meghan Proehl Wilder 2020 Irrevocable Trust (1) |
| Common Stock | | | | | | | | 35767 | I | By Sean Michael Proehl 2020 Irrevocable Trust Dated December 18, 2020 (1) |
| Common Stock | | | | | | | | 2905544 | I | By Proehl Investment Ventures LLC (1) |
| Common Stock | | | | | | | | 152857 | I | By Proehl Family Trust (1) |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 3) | 2. Conversion or Exercise Price of Derivative Security | 3. Trans. Date | 3A. Deemed Execution Date, if any | 4. Trans. 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 | 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 of Derivative Security: 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 |
| Explanation of Responses: |
| (1) | Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein, and the inclusion of these shares in this report shall not be deemed an admission of beneficial ownership of all of the reported shares for purposes of Section 16 or for any other purpose. |
Reporting Owners
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| Reporting Owner Name / Address | Relationships |
| Director | 10% Owner | Officer | Other |
PROEHL GERALD T
C/O DERMATA THERAPEUTICS, INC.
3525 DEL MAR HEIGHTS RD., #332
SAN DIEGO, CA 92130 | X | X | President, CEO and Chairman |
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Signatures
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| /s/ Gerald T. Proehl | | 11/26/2021 |
| **Signature of Reporting Person | Date |
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