SEC Form 4
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*
TL VENTURES V LP

(Last) (First) (Middle)
700 BUILDING, 435 DEVON PARK DRIVE

(Street)
WAYNE PA 19087-1990

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
COMBINATORX, INC [ CRXX ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director X 10% Owner
Officer (give title below) Other (specify below)
3. Date of Earliest Transaction (Month/Day/Year)
11/15/2005
4. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
Form filed by One Reporting Person
X Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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 11/15/2005 C 834,224 A (1) 834,224 D(3)
Common Stock 11/15/2005 C 748,951 A (2) 748,951 D(3)
Common Stock 11/15/2005 C 145,680 A (2) 145,680 D(3)
Common Stock 11/15/2005 C 14,409 A (1) 14,409 D(4)
Common Stock 11/15/2005 C 12,954 A (2) 12,959 D(4)
Common Stock 11/15/2005 C 2,519 A (2) 2,519 D(4)
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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
Series B Preferred Stock (1) 11/15/2005 C 1,311,300 (1) (1) Common Stock 834,224 (1) 0 D(3)
Series B Preferred Stock (1) 11/15/2005 C 22,650 (1) (1) Common Stock 14,409 (1) 0 D(4)
Series C Preferred Stock (2) 11/15/2005 C 1,310,664 (2) (2) Common Stock 748,951 (2) 0 D(3)
Series C Preferred Stock (2) 11/15/2005 C 22,669 (2) (2) Common Stock 12,954 (2) 0 D(4)
Series D Preferred Stock (2) 11/15/2005 C 254,940 (2) (2) Common Stock 145,680 (2) 0 D(3)
Series D Preferred Stock (2) 11/15/2005 C 4,409 (2) (2) Common Stock 2,519 (2) 0 D(4)
1. Name and Address of Reporting Person*
TL VENTURES V LP

(Last) (First) (Middle)
700 BUILDING, 435 DEVON PARK DRIVE

(Street)
WAYNE PA 19087-1990

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
Director X 10% Owner
Officer (give title below) Other (specify below)
1. Name and Address of Reporting Person*
TL VENTURES V INTERFUND LP

(Last) (First) (Middle)
700 BUILDING, 435 DEVON PARK DRIVE

(Street)
WAYNE PA 19087-1990

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
Director 10% Owner
Officer (give title below) X Other (specify below)
Co-Investor, TL Ventures V LP
1. Name and Address of Reporting Person*
KEITH ROBERT E JR

(Last) (First) (Middle)
700 BUILDING, 435 DEVON PARK DRIVE

(Street)
WAYNE PA 19087-1990

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
Director 10% Owner
X Officer (give title below) Other (specify below)
CEO, President
1. Name and Address of Reporting Person*
DENINO MARK J

(Last) (First) (Middle)
700 BUILDING, 435 DEVON PARK DRIVE

(Street)
WAYNE PA 19087-1990

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
Director 10% Owner
X Officer (give title below) Other (specify below)
Vice President, Secretary
1. Name and Address of Reporting Person*
MOLLER CHRISTOPHER

(Last) (First) (Middle)
700 BUILDING, 435 DEVON PARK DRIVE

(Street)
WAYNE PA 19087-1990

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
X Director 10% Owner
Officer (give title below) Other (specify below)
1. Name and Address of Reporting Person*
TL VENTURES V LLC

(Last) (First) (Middle)
700 BUILDING, 435 DEVON PARK DRIVE

(Street)
WAYNE PA 19087-1990

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
Director 10% Owner
Officer (give title below) X Other (specify below)
Gen'l Prtner TL Ventures V Mgt
1. Name and Address of Reporting Person*
TL VENTURES V MANAGEMENT LP

(Last) (First) (Middle)
700 BUILDING, 435 DEVON PARK DRIVE

(Street)
WAYNE PA 19087-1990

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
Director 10% Owner
Officer (give title below) X Other (specify below)
Gen'l Partner TL Ventures V LP
Explanation of Responses:
1. All of the outstanding shares of the Issuer's Series B Convertible Preferred Stock converted into 0.64 share of common stock automatically upon the closing of the Issuer's initial public offering.
2. All of the outstanding shares of the Issuer's Series C and Series D Convertible Preferred Stock converted into 0.57 share of common stock automatically upon the closing of the Issuer's initial public offering.
3. See Exhibit 99.1. Shares are held by TL Ventures V L.P. ("TL V"). TL Ventures V Management L.P. ("TLV Mgmt L.P"), the general partner of TL V, TL Ventures V LLC ("TLV LLC"), the general partner of TLV Mgmt L.P., and Robert E. Keith, Jr., Mark J. DeNino, and Christopher Moller Ph.D., the members of the executive board of TLV LLC, may be deemed to share voting and dispositive power over the shares held by TL V. Such persons and entities disclaim beneficial ownership of shares held by TL V except to the extent of any pecuniary interest therein.
4. See Exhibit 99.1. Shares are held by TL Ventures V Interfund L.P. ("TL V Interfund"). TL V LLC, the general partner of TL V Interfund, and Robert E. Keith, Jr., Mark J. DeNino, and Christopher Moller Ph.D., the members of the executive board of TL V LLC, may be deemed to share voting and dispositive power over the shares held by TL V Interfund. Such persons and entities disclaim beneficial ownership of shares held by TL V Interfund except to the extent of any pecuniary interest therein.
/s/ Pamela Strisofsky as Attorney in Fact 11/16/2005
** 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).
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