SEC FORM 4

SEC Form 4

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

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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^*

TREU JESSE I

(Last)

(First)

(Middle)

C/O DOMAIN ASSOCIATES, LLC

ONE PALMER SQUARE

(Street)

PRINCETON

08542

(City)

(State)

(Zip)

2. Issuer Name and Ticker or Trading Symbol
REVA Medical, Inc. [ RVA ]

5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)

Director	X	10% Owner
Officer (give title below)		Other (specify below)

3. Date of Earliest Transaction (Month/Day/Year)
12/16/2010

4. 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 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)
1. Title of Security (Instr. 3)	2. Transaction Date (Month/Day/Year)	2A. Deemed Execution Date, if any (Month/Day/Year)	Code	V	Amount	(A) or (D)	Price		6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)	7. Nature of Indirect Beneficial Ownership (Instr. 4)
Common Stock	12/16/2010		C		2,394,417	A	⁽¹⁾	2,394,417	I	By Domain Partners V, L.P.⁽⁸⁾
Common Stock	12/16/2010		C		620,256	A	⁽²⁾	3,014,673	I	By Domain Partners V, L.P.⁽⁸⁾
Common Stock	12/16/2010		C		36,302	A	⁽¹⁾	3,050,975	I	By Domain Partners V, L.P.⁽⁸⁾
Common Stock	12/16/2010		C		15,128	A	⁽⁷⁾	3,066,103	I	By Domain Partners V, L.P.⁽⁸⁾
Common Stock	12/16/2010		C		48,767	A	⁽²⁾	3,114,870	I	By Domain Partners V, L.P.⁽⁸⁾
Common Stock	12/16/2010		X		50,365	A	$6.5066	3,165,235	I	By Domain Partners V, L.P.⁽⁸⁾
Common Stock	12/16/2010		X		1,972,804	A	$3.28	5,138,039	I	By Domain Partners V, L.P.⁽⁸⁾
Common Stock	12/16/2010		J⁽³⁾		124,544	A	$6.5066	5,262,583	I	By Domain Partners V, L.P.⁽⁸⁾
Common Stock	12/16/2010		C		56,563	A	⁽¹⁾	56,563	I	By DP V Associates, L.P.⁽⁸⁾
Common Stock	12/16/2010		C		14,652	A	⁽²⁾	71,215	I	By DP V Associates, L.P.⁽⁸⁾
Common Stock	12/16/2010		C		858	A	⁽¹⁾	72,073	I	By DP V Associates, L.P.⁽⁸⁾
Common Stock	12/16/2010		C		358	A	⁽⁷⁾	72,431	I	By DP V Associates, L.P.⁽⁸⁾
Common Stock	12/16/2010		C		1,152	A	⁽²⁾	73,583	I	By DP V Associates, L.P.⁽⁸⁾
Common Stock	12/16/2010		X		1,190	A	$6.5066	74,773	I	By DP V Associates, L.P.⁽⁸⁾
Common Stock	12/16/2010		X		46,606	A	$3.28	121,379	I	By DP V Associates, L.P.⁽⁸⁾
Common Stock	12/16/2010		J⁽³⁾		2,943	A	$6.5045	124,322	I	By DP V Associates, L.P.⁽⁸⁾

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)
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)	Code	V	(A)	(D)	Date Exercisable	Expiration Date	Title	Amount or Number of Shares	8. Price of Derivative Security (Instr. 5)		10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)	11. Nature of Indirect Beneficial Ownership (Instr. 4)
Series E Convertible Preferred Stock	⁽¹⁾	12/16/2010		C			2,394,417	⁽¹⁾	⁽¹⁾	Common Stock	2,394,417	$0	0	I	By Domain Partners V, L.P.⁽⁸⁾
Series H Convertible Preferred Stock	⁽²⁾	12/16/2010		C			620,256	⁽²⁾	⁽²⁾	Common Stock	620,256	$0	0	I	By Domain Partners V, L.P.⁽⁸⁾
Warrants to Purchase Series E Convertible Preferred Stock	$6.0383	12/16/2010		X			80,894	⁽⁴⁾	⁽⁴⁾	Series E Convertible Preferred Stock	36,302⁽⁵⁾	$0	0	I	By Domain Partners V, L.P.⁽⁸⁾
Series E Convertible Preferred Stock	⁽¹⁾	12/16/2010		J⁽⁶⁾		36,302		⁽¹⁾	⁽¹⁾	Common Stock	36,302	$0	36,302	I	By Domain Partners V, L.P.⁽⁸⁾
Series E Convertible Preferred Stock	⁽¹⁾	12/16/2010		C			36,302	⁽¹⁾	⁽¹⁾	Common Stock	36,302	$0	0	I	By Domain Partners V, L.P.⁽⁸⁾
Warrants to Purchase Series F Convertible Preferred Stock	$3.28	12/16/2010		X			21,593	⁽⁴⁾	⁽⁴⁾	Series F Convertible Preferred Stock	15,128⁽⁵⁾	$0	0	I	By Domain Partners V, L.P.⁽⁸⁾
Series F Convertible Preferred Stock	⁽⁷⁾	12/16/2010		J⁽⁶⁾		15,128		⁽⁷⁾	⁽⁷⁾	Common Stock	15,128	$0	15,128	I	By Domain Partners V, L.P.⁽⁸⁾
Series F Convertible Preferred Stock	⁽⁷⁾	12/16/2010		C			15,128	⁽⁷⁾	⁽⁷⁾	Common Stock	15,128	$0	0	I	By Domain Partners V, L.P.⁽⁸⁾
Warrants to Purchase Series H Convertible Preferred Stock	$6.5066	12/16/2010		X			120,115	⁽⁴⁾	⁽⁴⁾	Series H Convertible Preferred Stock	48,767⁽⁵⁾	$0	0	I	By Domain Partners V, L.P.⁽⁸⁾
Series H Convertible Preferred Stock	⁽²⁾	12/16/2010		J⁽⁶⁾		48,767		⁽²⁾	⁽²⁾	Common Stock	48,767	$0	48,767	I	By Domain Partners V, L.P.⁽⁸⁾
Series H Convertible Preferred Stock	⁽²⁾	12/16/2010		C			48,767	⁽²⁾	⁽²⁾	Common Stock	48,767	$0	0	I	By Domain Partners V, L.P.⁽⁸⁾
Warrants to Purchase Comon Stock	$6.5066	12/16/2010		X			124,051	⁽⁴⁾	⁽⁴⁾	Common Stock	50,365⁽⁵⁾	$0	0	I	By Domain Partners V, L.P.⁽⁸⁾
Convertible Promissory Notes	$3.28	12/16/2010		C			$6,470,794.02	⁽⁴⁾	⁽⁴⁾	Common Stock	1,972,804	$0	0	I	By Domain Partners V, L.P.⁽⁸⁾
Series E Convertible Preferred Stock	⁽¹⁾	12/16/2010		C			56,563	⁽¹⁾	⁽¹⁾	Common Stock	56,563	$0	0	I	By DP V Associates, L.P.⁽⁸⁾
Series H Convertible Preferred Stock	⁽²⁾	12/16/2010		C			14,652	⁽²⁾	⁽²⁾	Common Stock	14,652	$0	0	I	By DP V Associates, L.P.⁽⁸⁾
Warrants to purchase Series E Convertible Preferred Stock	$6.0383	12/16/2010		X			1,911	⁽⁴⁾	⁽⁴⁾	Series E Convertible Preferred Stock	858⁽⁵⁾	$0	0	I	By DP V Associates, L.P.⁽⁸⁾
Series E Convertible Preferred Stock	⁽¹⁾	12/16/2010		J⁽⁶⁾		858		⁽¹⁾	⁽¹⁾	Common Stock	858	$0	858	I	By DP V Associates, L.P.⁽⁸⁾
Series E Convertible Preferred Stock	⁽¹⁾	12/16/2010		C			858	⁽¹⁾	⁽¹⁾	Common Stock	858	$0	0	I	By DP V Associates, L.P.⁽⁸⁾
Warrant to purchase Series F Convertible Preferred Stock	$3.28	12/16/2010		X			510	⁽⁴⁾	⁽⁴⁾	Series F Convertible Preferred Stock	358⁽⁵⁾	$0	0	I	By DP V Associates, L.P.⁽⁸⁾
Series F Convertible Preferred Stock	⁽⁷⁾	12/16/2010		J⁽⁶⁾		358		⁽⁷⁾	⁽⁷⁾	Common Stock	358	$0	358	I	By DP V Associates, L.P.⁽⁸⁾
Series F Convertible Preferred Stock	⁽⁷⁾	12/16/2010		C			358	⁽⁷⁾	⁽⁷⁾	Common Stock	358	$0	0	I	By DP V Associates, L.P.⁽⁸⁾
Warrants to purchase Series H Convertible Preferred Stock	$6.5066	12/16/2010		X			2,837	⁽⁴⁾	⁽⁴⁾	Series H Convertible Preferred Stock	1,152⁽⁵⁾	$0	0	I	By DP V Associates, L.P.⁽⁸⁾
Series H Convertible Preferred Stock	⁽²⁾	12/16/2010		J⁽⁶⁾		1,152		⁽²⁾	⁽²⁾	Common Stock	1,152	$0	1,152	I	By DP V Associates, L.P.⁽⁸⁾
Series H Convertible Preferred Stock	⁽²⁾	12/16/2010		C			1,152	⁽²⁾	⁽²⁾	Common Stock	1,152	$0	0	I	By DP V Associates, L.P.⁽⁸⁾
Warrants to purchase Common Stock	$6.5066	12/16/2010		X			2,930	⁽⁴⁾	⁽⁴⁾	Common Stock	1,190⁽⁵⁾	$0	0	I	By DP V Associates, L.P.⁽⁸⁾
Convertible Promissory Notes	$3.28	12/16/2010		C			$152,857.55	⁽⁴⁾	⁽⁴⁾	Common Stock	46,606	$0	0	I	By DP V Associates, L.P.⁽⁸⁾

Explanation of Responses:

1. Upon the closing of the Issuer's initial public offering, the Series E Convertible Preferred Stock automatically converted into REVA Medical, Inc. common stock on a 1-for-1 basis for no additional consideration.

2. Upon the closing of the Issuer's initial public offering, the Series H Convertible Preferred Stock automatically converted into REVA Medical, Inc. common stock on a 1-for-1 basis for no additional consideration.

3. Upon the closing of the Issuer's initial public offering, the reporting person was issued a stock dividend as a holder of record of Series H Convertible Preferred Stock immediately prior to the closing of the Issuer's initial public offering.

4. Upon the closing of the Issuer's initial public offering, all warrants were exercised through their respective cashless exercise provisions and all Convertible Promissory Notes, plus accrued interest, were converted.

5. Reflects net shares acquired following cashless exercise of all warrants.

6. Acquisition of preferred stock through the exercise of warrants.

7. Upon the closing of the Issuer's initial public offering, the Series F Convertible Preferred Stock automatically converted into REVA Medical, Inc. common stock on a 1-for-1 basis for no additional consideration.

8. The Reporting Person is a Managing Member of One Palmer Square Associates V, LLC, which is the sole general partner of Domain Partners V, L.P. and DP V Associates, L.P. The Reporting Person has elected to report as indirectly beneficially owned the entire number of securities beneficially owned by each such entity. The Reporting Person disclaims beneficial ownership of any securities, and any proceeds thereof, that exceed his or her pecuniary interest therein and/or that are not actually distributed to him or her.

Remarks:

	/s/ Kathleen K. Shoemaker, Attorney-in-Fact	12/20/2010
	** 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).
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