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