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