Statement of Changes in Beneficial Ownership (4)
March 24 2020 - 7:50PM
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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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
*
TULLIS DICKERSON CAPITAL FOCUS III, L.P. |
2. Issuer Name and Ticker or Trading Symbol
EXAGEN INC.
[
XGN
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
_____ Director __X__ 10% Owner _____ Officer (give title below) _____ Other (specify below)
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(Last)
(First)
(Middle)
11770 US HIGHWAY ONE, SUITE 503 |
3. Date of Earliest Transaction
(MM/DD/YYYY)
3/20/2020 |
(Street)
PALM BEACH GARDENS, FL 33408
(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)
___ Form filed by One Reporting Person
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X
_ 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 | 3/20/2020 | | J(1) | | 164420 (1) | D | $0.00 | 1625165 | I | See footnote (2) |
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) | Tullis and Tullis Growth, respectively, (as each is defined in Footnote (2) below) distributed in the aggregate 164,420 shares of Common Stock of Exagen Inc. to their respective non-affiliate limited partners on a pro rata basis, for no consideration. |
(2) | The shares reported on this form are held of record by Tullis-Dickerson Capital Focus III, L.P. ("Tullis"), Tullis Growth Fund, L.P. ("Tullis Growth") and Tullis Growth Fund II, L.P. ("Tullis Growth II"). Tullis-Dickerson Partners III, LLC ("Tullis Partners") is the general partner of Tullis and may be deemed to beneficially own the securities held by Tullis. Tullis Growth Partners, LLC and Tullis Growth Partners II, LLC are the general partners of Tullis Growth and Tullis Growth II, respectively, and may be deemed to beneficially own the securities held by Tullis Growth and Tullis Growth II. James L.L. Tullis is a Principal of each of the foregoing entities and may be deemed to possess voting and investment control over, and may be deemed to have an indirect beneficial ownership with respect to, the shares held by Tullis, Tullis Growth and Tullis Growth II. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
TULLIS DICKERSON CAPITAL FOCUS III, L.P. 11770 US HIGHWAY ONE, SUITE 503 PALM BEACH GARDENS, FL 33408 |
| X |
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Tullis Growth Fund, L.P. 11770 US HIGHWAY ONE, SUITE 503 PALM BEACH GARDENS, FL 33408 |
| X |
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TULLIS GROWTH FUND II, L.P. 11770 US HIGHWAY ONE, SUITE 503 PALM BEACH GARDENS, FL 33408 |
| X |
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TULLIS DICKERSON PARTNERS III, L.L.C. 11770 US HIGHWAY ONE, SUITE 503 PALM BEACH GARDENS, FL 33408 |
| X |
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Signatures
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Tullis-Dickerson Capital Focus III, L.P., By: Tullis-Dickerson Partners, L.L.C., its general partner, /s/ James L. L. Tullis, Name: James L.L. Tullis, Title: Manager | | 3/24/2020 |
**Signature of Reporting Person | Date |
Tullis Growth Fund, L.P., By: Tullis-Growth Partners, L.L.C., its general partner, /s/ James L. L. Tullis, Name: James L.L. Tullis, Title: Manager | | 3/24/2020 |
**Signature of Reporting Person | Date |
Tullis Growth Fund II, L.P., By: Tullis-Growth Partners II, L.L.C., its general partner, /s/ James L. L. Tullis, Name: James L.L. Tullis, Title: Manager | | 3/24/2020 |
**Signature of Reporting Person | Date |
Tullis-Dickerson Partners III, L.L.C., /s/ James L. L. Tullis, Name: James L.L. Tullis, Title: Manager | | 3/24/2020 |
**Signature of Reporting Person | Date |
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