FORM 4 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940 |
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). |
1. Name and Address of Reporting Person*
(Street)
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2. Issuer Name and Ticker or Trading Symbol
ANESIVA, INC. [ ANSV ] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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3. Date of Earliest Transaction
(Month/Day/Year) 12/15/2005 | ||||||||||||||||||||||||||
4. If Amendment, Date of Original Filed
(Month/Day/Year) 12/19/2005 |
6. Individual or Joint/Group Filing (Check Applicable Line)
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned | ||||||||||
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1. Title of Security (Instr. 3) | 2. Transaction Date (Month/Day/Year) | 2A. Deemed Execution Date, if any (Month/Day/Year) | 3. Transaction Code (Instr. 8) | 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) | 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) | 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 7. Nature of Indirect Beneficial Ownership (Instr. 4) | |||
Code | V | Amount | (A) or (D) | Price | ||||||
Common Stock | 64 | D | ||||||||
Common Stock | 12/15/2005 | A | 1,122,863(1) | A | $0(2) | 1,148,524 | I | By Sofinnova Venture Partners V, LP(3) | ||
Common Stock | 12/15/2005 | A | 36,941(1) | A | $0(2) | 37,145 | I | By Sofinnova Venture Affiliates V, LP(4) | ||
Common Stock | 12/15/2005 | A | 17,216(1) | A | $0(2) | 17,600 | I | By Sofinnova Venture Principals V, LP(5) |
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||||||||||
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1. Title of Derivative Security (Instr. 3) | 2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) | 6. Date Exercisable and Expiration Date (Month/Day/Year) | 7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4) | 8. Price of Derivative Security (Instr. 5) | 9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) | 10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 11. Nature of Indirect Beneficial Ownership (Instr. 4) | ||||
Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||||||
Stock Option (right to buy) | $9.8(6) | 12/16/2005 | A | 12,500(1) | 12/16/2005(7) | 12/16/2015 | Common Stock | 12,500 | $0 | 12,500 | D | ||||
Stock Option (right to buy) | $9.8(6) | 12/15/2005 | A | 37,500(1) | 12/16/2005(8) | 12/16/2015 | Common Stock | 37,500 | $0 | 37,500 | D |
Explanation of Responses: |
1. Number of shares reflects 1 for 4 reverse stock-split effected by the Issuer on 12/15/05. |
2. Shares issued as consideration pursuant to an Agreement and Plan of Merger dated September 23, 2005 between the Issuer and AlgoRx Inc. On the effective date of the merger, the closing price of the Issuer's common stock was $9.80 per share (which reflects a 1 for 4 reverse stock-split effected by the Issuer on 12/15/05, the effective date of the merger). |
3. The shares are owned by Sofinnova Venture Partners V, LP ("SV Partners"). The Reporting Person is the Managing Director of SV Partners. He disclaims beneficial ownership of the shares held by SV Partners, except to the extent of his pecuniary interest therein. |
4. The shares are owned by Sofinnova Venture Affiliates V, LP ("SV Affiliates"). The Reporting Person is the Managing Director of SV Affiliates. He disclaims beneficial ownership of the shares held by SV Affiliates, except to the extent of his pecuniary interest therein. |
5. The shares are owned by Sofinnova Venture Principals V, LP ("SV Principals"). The Reporting Person is the Managing Director of SV Principals. He disclaims beneficial ownership of the shares held by SV Principals, except to the extent of his pecuniary interest therein. |
6. Exercise price reflects 1 for 4 reverse stock-split effected by the Issuer on 12/15/05. |
7. Option is exercisable immediately. Shares subject to the option vest as follows: 1/48 of shares become exercisable in equal monthly increments over 4 years from the grant date. |
8. Option is exercisable immediately. Shares subject to the option vest as follows: 12,500 of the shares become exercisable immediately as of the grant date and the remaining shares will vest in equal monthly increments over 4 years from the grant date. |
Remarks: |
Patrick A. Broderick as Attorney in Fact for Michael F. Powell | 01/26/2007 | |
** Signature of Reporting Person | Date | |
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | ||
* If the form is filed by more than one reporting person, see Instruction 4 (b)(v). | ||
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). | ||
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. | ||
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. |