Statement of Changes in Beneficial Ownership (4)
July 26 2017 - 5:11PM
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).
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0287
Estimated average burden
hours per response...
0.5
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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
*
Venkatesan Jay
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2. Issuer Name
and
Ticker or Trading Symbol
ALPINE IMMUNE SCIENCES, INC.
[
ALPN
]
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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
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(Last)
(First)
(Middle)
C/O ALPINE IMMUNE SCIENCES, INC., 201 ELLIOTT AVENUE WEST, SUITE 230
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3. Date of Earliest Transaction
(MM/DD/YYYY)
7/24/2017
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(Street)
SEATTLE, WA 98119
(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
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7/24/2017
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J
(1)
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18633
(1)
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A
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(1)
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18633
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I
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By Raj Venkatesan as UTMA custodian for Reid Coleman Venkatesan
(2)
(4)
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Common Stock
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7/24/2017
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J
(1)
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18633
(1)
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A
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(1)
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18633
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I
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By Raj Venkatesan as UTMA custodian for Nathaniel Graham Venkatesan
(2)
(4)
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Common Stock
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7/24/2017
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A
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21739
(1)
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A
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(1)
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21739
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D
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Common Stock
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7/24/2017
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J
(1)
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3803906
(1)
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A
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(1)
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3803906
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I
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Alpine Immunosciences, L.P.
(3)
(4)
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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)
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2. Conversion or Exercise Price of Derivative Security
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3. Trans. Date
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3A. Deemed Execution Date, if any
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4. Trans. Code
(Instr. 8)
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5. Number of Derivative Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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6. Date Exercisable and Expiration Date
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7. Title and Amount of Securities Underlying Derivative Security
(Instr. 3 and 4)
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8. Price of Derivative Security
(Instr. 5)
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9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4)
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10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4)
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11. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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(A)
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(D)
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Date Exercisable
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Expiration Date
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Title
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Amount or Number of Shares
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Employee Stock Option (right to buy)
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$0.45
(1)
(5)
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7/24/2017
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A
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90063
(1)
(5)
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(6)
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12/15/2025
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Common Stock
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90063
(1)
(5)
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$0.00
(5)
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90063
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D
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Explanation of Responses:
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(1)
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Pursuant to that certain Agreement and Plan of Merger and Reorganization (the "Merger Agreement"), dated as of April 18, 2017, by and among the Issuer, Nautilus Merger Sub, Inc. and the corporation then known as Alpine Immune Sciences, Inc. ("Old Alpine"), each share of Old Alpine common stock was converted into 0.4969 shares of the Issuer's common stock (the "Exchange Ratio").
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(2)
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These shares are held by Raj Venkatesan as custodian for Reporting Person's sons under California Uniform Transfers to Minors Act.
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(3)
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Alpine BioVentures GP, LLC is the general partner of Alpine Immunosciences, L.P. Dr. Venkatesan is a Managing Partner of Alpine BioVentures GP, LLC. Dr. Venkatesan is also a limited partner of Alpine Immunosciences, L.P. By virtue of such relationships, Dr. Venkatesan may be deemed to have voting and investment power with respect to the shares held by Alpine Immunosciences, L.P. and as a result may be deemed to have beneficial ownership of such shares.
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(4)
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The Reporting Person disclaims beneficial ownership of the shares of common stock reported herein except to the extent of his pecuniary interest therein, if any, and this report shall not be deemed an admission that the Reporting Person is the beneficial owner of the shares for purposes of Section 16 of the Securities Exchange Act of 1934, as amended, or for any other purpose.
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(5)
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Each option to purchase shares of Old Alpine outstanding and unexercised was assumed by the Issuer pursuant to the Merger Agreement and converted into an option, subject to vesting, to purchase shares of common stock of the Issuer, with the number of shares of the Issuer's common stock underlying such option and the exercise price for such option adjusted to reflect the Exchange Ratio.
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(6)
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The Reporting Person was initially granted an option to acquire 300,000 shares, 75,000 shares of which vested on May 25, 2016, and the remaining shares vested or vest in 36 substantially equal monthly installments starting on September 1, 2016, subject to the Reporting person's continued service with the Issuer and certain change of control provisions.
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Remarks:
Ex. 24.1 - Power of Attorney (incorporated by reference to the Power of Attorney filed as Exhibit 24.1 to the Form 3 filed by the Reporting Person on July 26, 2017)
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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Venkatesan Jay
C/O ALPINE IMMUNE SCIENCES, INC.
201 ELLIOTT AVENUE WEST, SUITE 230
SEATTLE, WA 98119
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X
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X
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President
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Signatures
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/s/ Paul Rickey, attorney-in-fact
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7/26/2017
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 4(b)(v).
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**
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Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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Note:
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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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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 control number.
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