FORM 5 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 ANNUAL 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). | ||||||||||||||||
Form 3 Holdings Reported. | |||||||||||||||||
Form 4 Transactions Reported. |
1. Name and Address of Reporting Person*
(Street)
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2. Issuer Name and Ticker or Trading Symbol
SANTARUS INC [ SNTS ] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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3. Statement for Issuer's Fiscal Year Ended
(Month/Day/Year) 12/31/2004 | ||||||||||||||||||||||||||
4. If Amendment, Date of Original Filed
(Month/Day/Year) |
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 at end of Issuer's Fiscal Year (Instr. 3 and 4) | 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 7. Nature of Indirect Beneficial Ownership (Instr. 4) | ||||||||
Amount | (A) or (D) | Price | |||||||||||||
Common Stock | 03/31/2004 | C | 1,137,656 | A | (2) | 1,137,656 | I | by S.R.One, Limited(1) | |||||||
Common stock | 10/25/2004 | X | 2,857 | A | $1.225 | 1,140,513 | I | by S.R.One, Limited(1) | |||||||
Common stock | 10/25/2004 | X | 25,000 | A | $9 | 1,165,513 | I | by S.R.One, Limited(1) |
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) | |||
(A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | |||||||||
Series D Preferred stock | (2) | 03/31/2004 | C | 3,981,842 | (3) | (4) | Common stock | 1,137,656 | (2) | 0 | I | by S.R. One, Limited(1) | ||
Stock Option (right to buy) | $1.75 | 07/27/2004 | J | 8,571 | 12/31/2004 | 12/03/2013 | Common stock | 8,571 | (5) | 0 | I | by S.R.One, Limited(1)(5) | ||
Stock Option (right to buy) | $1.225 | 10/25/2004 | X | 2,857 | 07/30/2003 | 07/30/2013 | Common stock | 2,857 | $1.225 | 0 | I | by S.R.One, Limited(1) | ||
Stock Option (right to buy) | $9 | 10/25/2004 | X | 25,000 | 04/01/2004 | 04/01/2014 | Common stock | 25,000 | $9 | 0 | I | by S.R.One, Limited(1) |
Explanation of Responses: |
1. These options were granted to the Reporting Person, a trustee and officer of S.R. One, Limited ("SROne"). Reporting Person is obligated to transfer any shares issued under the options to SROne and disclaims beneficial ownership of those shares and any other shares included in this report except to the extent of her pecuniary interest in SROne. |
2. Each share of Series D Preferred stock was automatically converted by its terms into 0.28571 shares of Common stock upon the consummation of the Issuer's initial public offering. |
3. Immediately convertible. |
4. The expiration date is not relevant to this transaction. |
5. Reporting Person ceased being a director of Issuer on July 27, 2004. The options originally granted on December 3, 2003 and not exercisable until December 31, 2004 have lapsed since they were not vested at the time the Reporting Person ceased being a director of the Issuer. |
Maxine Gowen | 02/07/2005 | |
** 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. |