0001209191-16-133560.txt : 20160720 0001209191-16-133560.hdr.sgml : 20160720 20160720211019 ACCESSION NUMBER: 0001209191-16-133560 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 2 CONFORMED PERIOD OF REPORT: 20160720 FILED AS OF DATE: 20160720 DATE AS OF CHANGE: 20160720 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: IMPINJ INC CENTRAL INDEX KEY: 0001114995 STANDARD INDUSTRIAL CLASSIFICATION: ELECTRONIC COMPONENTS, NEC [3679] IRS NUMBER: 912041398 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 400 FAIRVIEW AVENUE NORTH STREET 2: SUITE 1200 CITY: SEATTLE STATE: WA ZIP: 98109 BUSINESS PHONE: 206-517-5300 MAIL ADDRESS: STREET 1: 400 FAIRVIEW AVENUE NORTH STREET 2: SUITE 1200 CITY: SEATTLE STATE: WA ZIP: 98109 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: ARCH VENTURE PARTNERS V LLC CENTRAL INDEX KEY: 0001274408 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-37824 FILM NUMBER: 161776386 BUSINESS ADDRESS: STREET 1: C/O ARCH VENTURE PARTNERS STREET 2: 8755 W. HIGGINS AVE. #1025 CITY: CHICAGO STATE: IL ZIP: 60631 BUSINESS PHONE: 7733806600 MAIL ADDRESS: STREET 1: C/O ARCH VENTURE PARTNERS STREET 2: 8755 W. HIGGINS AVE. #1025 CITY: CHICAGO STATE: IL ZIP: 60631 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: ARCH VENTURE PARTNERS V LP CENTRAL INDEX KEY: 0001274406 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-37824 FILM NUMBER: 161776387 BUSINESS ADDRESS: STREET 1: C/O ARCH VENTURE PARTNERS STREET 2: 8755 W. HIGGINS RD. #1025 CITY: CHICAGO STATE: IL ZIP: 60631 BUSINESS PHONE: 7733806600 MAIL ADDRESS: STREET 1: C/O ARCH VENTURE PARTNERS STREET 2: 8755 W. HIGGINS RD. #1025 CITY: CHICAGO STATE: IL ZIP: 60631 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: LAZARUS STEVEN CENTRAL INDEX KEY: 0001054117 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-37824 FILM NUMBER: 161776388 MAIL ADDRESS: STREET 1: 8755 WEST HIGGINS ROAD STREET 2: SUITE 1025 CITY: CHICAGO STATE: IL ZIP: 60631 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: CRANDELL KEITH CENTRAL INDEX KEY: 0001219039 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-37824 FILM NUMBER: 161776390 MAIL ADDRESS: STREET 1: 8755 W. HIGGINS ROAD STREET 2: SUITE 1025 CITY: CHICAGO STATE: IL ZIP: 60631 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: ARCH VENTURE FUND V LP CENTRAL INDEX KEY: 0001117120 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-37824 FILM NUMBER: 161776392 BUSINESS ADDRESS: STREET 1: 8755 W. HIGGINS ROAD STREET 2: SUITE 1025 CITY: CHICAGO STATE: IL ZIP: 60631 BUSINESS PHONE: 7733806600 MAIL ADDRESS: STREET 1: 8755 W. HIGGINS ROAD STREET 2: SUITE 1025 CITY: CHICAGO STATE: IL ZIP: 60631 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: NELSEN ROBERT CENTRAL INDEX KEY: 0001219042 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-37824 FILM NUMBER: 161776389 MAIL ADDRESS: STREET 1: 8755 W. HIGGINS ROAD STREET 2: SUITE 1025 CITY: CHICAGO STATE: IL ZIP: 60631 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: ARCH V ENTREPRENEURS FUND LP CENTRAL INDEX KEY: 0001161740 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-37824 FILM NUMBER: 161776391 BUSINESS ADDRESS: STREET 1: 8755 W. HIGGINS ROAD STREET 2: SUITE 1025 CITY: CHICAGO STATE: IL ZIP: 60631 BUSINESS PHONE: 7733806600 MAIL ADDRESS: STREET 1: 8755 W. HIGGINS ROAD STREET 2: SUITE 1025 CITY: CHICAGO STATE: IL ZIP: 60631 3 1 doc3.xml FORM 3 SUBMISSION X0206 3 2016-07-20 0 0001114995 IMPINJ INC PI 0001117120 ARCH VENTURE FUND V LP 8755 WEST HIGGINS ROAD SUITE 1025 CHICAGO IL 60631 0 0 1 0 0001161740 ARCH V ENTREPRENEURS FUND LP 8755 WEST HIGGINS ROAD SUITE 1025 CHICAGO IL 60631 0 0 1 0 0001219039 CRANDELL KEITH 8755 WEST HIGGINS ROAD SUITE 1025 CHICAGO IL 60631 0 0 1 0 0001219042 NELSEN ROBERT 8755 WEST HIGGINS ROAD SUITE 1025 CHICAGO IL 60631 0 0 1 0 0001054117 LAZARUS STEVEN 8755 WEST HIGGINS ROAD SUITE 290 CHICAGO IL 60631 0 0 1 0 0001274406 ARCH VENTURE PARTNERS V LP 8755 WEST HIGGINS ROAD SUITE 1025 CHICAGO IL 60631 0 0 1 0 0001274408 ARCH VENTURE PARTNERS V LLC 8755 WEST HIGGINS ROAD SUITE 1025 CHICAGO IL 60631 0 0 1 0 No securities are beneficially held 0 D Series 1 Preferred Stock 0.00 Common Stock 820935 D Series 2 Preferred Stock 0.00 Common Stock 421684 D Series 2 Preferred Warrant (Right to Buy) 9.32 2017-06-30 Common Stock 32022 D Not applicable Reflects a 1-for-12 reverse stock split of the Issuer's outstanding shares effected July 8, 2016. The Series 1 Preferred Stock will automatically convert to shares of the Issuer's Common Stock upon the closing of the Issuer's initial public offering on a 1-for-1 basis. Each share has no expiration date. 815,666 of these shares are held of record by ARCH Venture Fund V, L.P.; and 5,269 of these shares are held of record by ARCH V Entrepreneurs Fund, L.P. ARCH Venture Partners V, L.P., as the sole general partner of ARCH Venture Fund V, L.P. and ARCH V Entrepreneurs Fund, L.P., may be deemed to beneficially own certain of the shares held of record by ARCH Venture Fund V, L.P. and ARCH V Entrepreneurs Fund, L.P., but disclaims beneficial ownership of such shares, in which it does not have an actual pecuniary interest. ARCH Venture Partners V, LLC, as the sole general partner of ARCH Venture Partners V, L.P., may be deemed to beneficially own certain of the shares held of record by ARCH Venture Fund V, L.P. and ARCH V Entrepreneurs Fund, L.P. but disclaims beneficial ownership of such shares, in which it does not have an actual pecuniary interest. Robert Nelsen, Keith Crandell and Steven Lazarus are managing directors of ARCH Venture Partners V, LLC, and may be deemed to beneficially own certain of the shares held of record by ARCH Venture Fund V, L.P. and ARCH V Entrepreneurs Fund, L.P. Mr. Nelsen, Mr. Crandell and Mr. Lazarus disclaim beneficial ownership of all shares held of record by ARCH Venture Fund V, L.P. and ARCH V Entrepreneurs Fund, L.P., in which they do not have an actual pecuniary interest. By virtue of their relationship as affiliated entities who have overlapping general partners and managing directors, ARCH Venture Fund V, L.P., ARCH V Entrepreneurs Fund, L.P., ARCH Venture Partners V, L.P., ARCH Venture Partners V, LLC and Mr. Crandell, Mr. Nelsen and Mr. Lazarus may be deemed to share the voting and investment control of the record shares. The Series 2 Preferred Stock will automatically convert to shares of the Issuer's Common Stock upon the closing of the Issuer's initial public offering on a 1.24996780424983-for-1 basis. 418,862 of these shares are held of record by ARCH Venture Fund V, L.P.; and 2,822 of these shares are held of record by ARCH V Entrepreneurs Fund, L.P. 31,808 of these warrants are held of record by ARCH Venture Fund V, L.P.; and 214 of these warrants are held of record by ARCH V Entrepreneurs Fund, L.P. Power of Attorney Mark McDonnell, as Attorney-in-Fact for Keith Crandell, as Managing Director of the general partner of the general partner of ARCH Venture Fund V, L.P. 2016-07-20 Mark McDonnell, as Attorney-in-Fact for Keith Crandell, as Managing Director of the general partner of ARCH V Entrepreneurs Fund, L.P. 2016-07-20 Mark McDonnell, as Attorney-in-Fact for Keith Crandell 2016-07-20 Mark McDonnell, as Attorney-in-Fact for Robert Nelsen 2016-07-20 Mark McDonnell, as Attorney-in-Fact for Steven Lazarus 2016-07-20 Mark McDonnell, as Attorney-in-Fact for Robert Nelsen, as Managing Director of the of ARCH Venture Partners V, L.P. 2016-07-20 Mark McDonnell, as Attorney-In-Fact for Robert Nelsen, as Managing Director for ARCH Venture Partners V LLC 2016-07-20 EX-24.3_667628 2 poa.txt POA DOCUMENT POWERS OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS, that each person whose signature appears below hereby constitutes and appoints Mark McDonnell his true and lawful attorney-in-fact, with full power of substitution, to sign any and all instruments, certificates and documents that may be necessary, desirable or appropriate to be executed on behalf of himself as an individual or in his capacity as a general partner of any partnership, pursuant to Sections 13 and 16 of the Securities Exchange Act of 1934, as amended (the "Exchange Act"), and any and all regulations promulgated thereunder, and to file the same, with all exhibits thereto, and any other documents in connection therewith, with the Securities and Exchange Commission, and with any other entity when and if such is mandated by the Exchange Act or by the By-laws of the National Association of Securities Dealers, Inc., granting unto said attorney-in-fact full power and authority to do and perform each and every act and thing necessary, desirable or appropriate, fully to all intents and purposes as he might or could do in person, thereby ratifying and confirming all that said attorney-in-fact, or his substitutes, may lawfully do or cause to be done by virtue hereof. IN WITNESS WHEREOF, this Power of Attorney has been signed as of the 8th day of June, 2004. ARCH VENTURE FUND V, L.P. By: ARCH Venture Partners V, L.P. Its General Partner By: ARCH Venture Partners V, LLC Its General Partner By: /s/ Keith Crandell Managing Director ARCH V ENTREPRENEURS FUND, L.P. By: ARCH Venture Partners V, L.P. Its General Partner By: ARCH Venture Partners V, LLC Its General Partner By: /s/ Keith Crandell Managing Director ARCH VENTURE PARTNERS V, L.P. By: ARCH Venture Partners V, LLC Its General Partner By: /s/ Keith Crandell Managing Director ARCH Venture Partners V, LLC By: /s/ Robert Nelsen Managing Director /s/ Steven Lazarus Steven Lazarus /s/ Keith Crandell Keith Crandell /s/ Robert Nelsen Robert Nelsen