0001209191-21-028401.txt : 20210426 0001209191-21-028401.hdr.sgml : 20210426 20210426190206 ACCESSION NUMBER: 0001209191-21-028401 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20210422 FILED AS OF DATE: 20210426 DATE AS OF CHANGE: 20210426 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: HAQUE PROMOD CENTRAL INDEX KEY: 0001089744 STATE OF INCORPORATION: CA FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-40353 FILM NUMBER: 21855445 MAIL ADDRESS: STREET 1: C/O NORWEST VENTURE PARTNERS STREET 2: 525 UNIVERSITY AVENUE, SUITE 800 CITY: PALO ALTO STATE: CA ZIP: 94301 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Crowe Jeffrey CENTRAL INDEX KEY: 0001535261 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-40353 FILM NUMBER: 21855446 MAIL ADDRESS: STREET 1: 525 UNIVERSITY AVENUE STREET 2: SUITE 800 CITY: PALO ALTO STATE: CA ZIP: 94301 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Norwest Venture Partners XIV, LP CENTRAL INDEX KEY: 0001842721 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-40353 FILM NUMBER: 21855447 BUSINESS ADDRESS: STREET 1: 525 UNIVERSITY AVENUE STREET 2: SUITE 800 CITY: PALO ALTO STATE: CA ZIP: 94301 BUSINESS PHONE: 650-321-8000 MAIL ADDRESS: STREET 1: 525 UNIVERSITY AVENUE STREET 2: SUITE 800 CITY: PALO ALTO STATE: CA ZIP: 94301 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Kossow Jon Erik CENTRAL INDEX KEY: 0001726084 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-40353 FILM NUMBER: 21855444 MAIL ADDRESS: STREET 1: 525 UNIVERSITY AVENUE, SUITE 800 CITY: PALO ALTO STATE: CA ZIP: 94025 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: IMPEL NEUROPHARMA INC CENTRAL INDEX KEY: 0001445499 STANDARD INDUSTRIAL CLASSIFICATION: PHARMACEUTICAL PREPARATIONS [2834] IRS NUMBER: 263058238 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 201 ELLIOTT AVE. W STREET 2: SUITE 260 CITY: SEATTLE STATE: WA ZIP: 98119 BUSINESS PHONE: 206-568-1466 MAIL ADDRESS: STREET 1: 201 ELLIOTT AVE. W STREET 2: SUITE 260 CITY: SEATTLE STATE: WA ZIP: 98119 4 1 doc4.xml FORM 4 SUBMISSION X0306 4 2021-04-22 0 0001445499 IMPEL NEUROPHARMA INC IMPL 0001842721 Norwest Venture Partners XIV, LP 525 UNIVERSITY AVENUE SUITE 800 PALO ALTO CA 94301 0 0 1 0 0001535261 Crowe Jeffrey 525 UNIVERSITY AVENUE SUITE 800 PALO ALTO CA 94301 0 0 1 0 0001089744 HAQUE PROMOD 525 UNIVERSITY AVENUE SUITE 800 PALO ALTO CA 94301 0 0 1 0 0001726084 Kossow Jon Erik 525 UNIVERSITY AVENUE SUITE 800 PALO ALTO CA 94301 0 0 1 0 5% Convertible Note due 2021 2021-04-22 4 J 0 1325893.04 0.00 A 2021-12-31 Common Stock 98927 1325893.04 D The convertible promissory note was issued by the issuer in March 2021 and the outstanding principal and accrued interest will automatically convert into the number of shares of the issuer's Common Stock set forth above upon the closing of the issuer's initial public offering (the "IPO") at $13.50 per share (90% of the IPO price). The conversion price became fixed upon pricing of the issuer's IPO on April 22, 2021. /s/ Matthew De Dominicis, Chief Financial Officer 2021-04-26 /s/ Matthew De Dominicis, Attorney-in-Fact for Jeffrey Crowe 2021-04-26 /s/ Matthew De Dominicis, Attorney-in-Fact for Promod Haque 2021-04-26 /s/ Matthew De Dominicis, Attorney-in-Fact for Jon Erik Kossow 2021-04-26