0000905718-21-001110.txt : 20210817
0000905718-21-001110.hdr.sgml : 20210817
20210817124946
ACCESSION NUMBER: 0000905718-21-001110
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20210817
FILED AS OF DATE: 20210817
DATE AS OF CHANGE: 20210817
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: HALE DAVID F
CENTRAL INDEX KEY: 0001024004
STANDARD INDUSTRIAL CLASSIFICATION: PHARMACEUTICAL PREPARATIONS [2834]
STATE OF INCORPORATION: CA
FISCAL YEAR END: 1231
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-40739
FILM NUMBER: 211182036
MAIL ADDRESS:
STREET 1: 1042-B NORTH EL CAMINO REAL, SUITE 430
CITY: ENCINITAS
STATE: CA
ZIP: 92024
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: Dermata Therapeutics, Inc.
CENTRAL INDEX KEY: 0001853816
STANDARD INDUSTRIAL CLASSIFICATION: PHARMACEUTICAL PREPARATIONS [2834]
IRS NUMBER: 000000000
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
BUSINESS ADDRESS:
STREET 1: 3525 DEL MAR HEIGHTS RD., #332
CITY: SAN DIEGO
STATE: CA
ZIP: 92130
BUSINESS PHONE: (858)-223-0882
MAIL ADDRESS:
STREET 1: 3525 DEL MAR HEIGHTS RD., #332
CITY: SAN DIEGO
STATE: CA
ZIP: 92130
4
1
dermata_fm4aug172021.xml
X0306
4
2021-08-17
0
0001853816
Dermata Therapeutics, Inc.
DRMA
0001024004
HALE DAVID F
3525 DEL MAR HEIGHTS RD., #332
SAN DIEGO
CA
92130
1
0
1
0
Common Stock
2021-08-17
4
C
0
44777
A
299411
I
By Hale BioVentures LLC
Common Stock
2021-08-17
4
C
0
12195
A
311606
I
By Hale BioVentures LLC
Common Stock
2021-08-17
4
C
0
20000
A
331606
I
By Hale BioVentures LLC
Common Stock
2021-08-17
4
C
0
174216
A
505822
I
By Hale BioVentures LLC
Common Stock
2021-08-17
4
C
0
27103
A
532925
I
By Hale BioVentures LLC
Common Stock
2021-08-17
4
P
0
35714
A
35714
I
By Hale Family Trust
Common Stock
3658
D
Common Stock
12195
I
By Hale Trading Company LP
Series 1d Preferred Stock
2021-08-17
4
C
0
302112
0
D
Common Stock
44777
0
I
By Hale BioVentures LLC
Series 1a Preferred Stock
2021-08-17
4
C
0
250000
0
D
Common Stock
12195
0
I
By Hale BioVentures LLC
Series 1b Preferred Stock
2021-08-17
4
C
0
410000
0
D
Common Stock
20000
0
I
By Hale BioVentures LLC
Series 1c Preferred Stock
2021-08-17
4
C
0
3571428
0
D
Common Stock
174216
0
I
By Hale BioVentures LLC
Series 1 Preferred Stock
2021-08-17
4
C
0
555622
0
D
Common Stock
27103
0
I
By Hale BioVentures LLC
Series 1a Warrants
2021-08-17
4
C
0
62500
0
D
2016-11-15
2026-03-14
Common Stock
3048
0
I
By Hale BioVentures LLC
Warrant to Purchase Common Stock
20.50
2021-08-17
4
C
0
3048
0
A
2016-11-15
2026-03-14
Common Stock
3048
3048
I
By Hale BioVentures LLC
Warrant to Purchase Common Stock
7.00
2021-08-17
4
P
0
35714
A
2021-08-17
2026-08-17
Common Stock
35714
35714
I
By Hale Family Trust
The Series 1d Preferred Stock automatically converted into Common Stock of the Issuer upon consummation of the Issuer's initial public offering (the "IPO"). The Series 1d Preferred Stock was convertible at any time and had no expiration date.
The Series 1a Preferred Stock converted into Common Stock of the Issuer upon consummation of the IPO. The Series 1a Preferred Stock was convertible at any time and had no expiration date.
The Series 1b Preferred Stock converted into Common Stock of the Issuer upon consummation of the IPO. The Series 1b Preferred Stock was convertible at any time and had no expiration date.
The Series 1c Preferred Stock converted into Common Stock of the Issuer upon consummation of the IPO. The Series 1c Preferred Stock was convertible at any time and had no expiration date.
The Series 1 Preferred Stock converted into Common Stock of the Issuer upon consummation of the IPO. The Series 1 Preferred Stock was convertible at any time and had no expiration date.
The Series 1a Preferred Warrants converted into warrants to purchase Common Stock in connection with the IPO.
Reporting Person disclaims beneficial ownership of these securities except to the extent of their 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 Person purchased 35,714 Units in the IPO at $7.00 per Unit. Each Unit consists of one share of Common Stock and one warrant to purchase one share of Common Stock.
/s/ Gerald T. Proehl, Attorney-in-Fact
2021-08-17