0000905718-21-001027.txt : 20210812 0000905718-21-001027.hdr.sgml : 20210812 20210812193548 ACCESSION NUMBER: 0000905718-21-001027 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 2 CONFORMED PERIOD OF REPORT: 20210812 FILED AS OF DATE: 20210812 DATE AS OF CHANGE: 20210812 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: HALE DAVID F CENTRAL INDEX KEY: 0001024004 STANDARD INDUSTRIAL CLASSIFICATION: PHARMACEUTICAL PREPARATIONS [2834] STATE OF INCORPORATION: CA FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-40739 FILM NUMBER: 211169269 MAIL ADDRESS: STREET 1: 1042-B NORTH EL CAMINO REAL, SUITE 430 CITY: ENCINITAS STATE: CA ZIP: 92024 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Dermata Therapeutics, Inc. CENTRAL INDEX KEY: 0001853816 STANDARD INDUSTRIAL CLASSIFICATION: PHARMACEUTICAL PREPARATIONS [2834] IRS NUMBER: 000000000 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 3525 DEL MAR HEIGHTS RD., #332 CITY: SAN DIEGO STATE: CA ZIP: 92130 BUSINESS PHONE: (858)-223-0882 MAIL ADDRESS: STREET 1: 3525 DEL MAR HEIGHTS RD., #332 CITY: SAN DIEGO STATE: CA ZIP: 92130 3 1 ownership.xml X0206 3 2021-08-12 0 0001853816 Dermata Therapeutics, Inc. DRMA 0001024004 HALE DAVID F 3525 DEL MAR HEIGHTS RD., #332 SAN DIEGO CA 92130 1 0 0 0 Common Stock 3658 D Common Stock 12195 I By Hale Trading Company LP Common Stock 254634 I By Hale BioVentures LLC Stock Option (Right to Buy) 5.74 2021-03-31 2031-03-31 Common Stock 12194 D Stock Option (Right to Buy) 5.74 2031-03-31 Common Stock 4878 D Series 1d Preferred Stock Common Stock 302112 I By Hale BioVentures LLC Series 1a Preferred Stock Common Stock 250000 I By Hale BioVentures LLC Series 1b Preferred Stock Common Stock 410000 I By Hale BioVentures LLC Series 1c Preferred Stock Common Stock 3571428 I By Hale BioVentures LLC Series 1 Preferred Stock Common Stock 555622 I By Hale BioVentures LLC Series 1a Warrants 2016-11-15 2026-03-14 Common Stock 62500 I By Hale BioVentures LLC Shares reported reflect the 1 for 20.5 stock split effected July 1, 2021 (the "Stock Split"). Options vest in 12 equal monthly installments commencing January 1, 2021. The Series 1d Preferred Stock is convertible into shares of Common Stock at a conversion ratio equal to 80% of the offering price in connection with the Issuer's initial public offering ("IPO"). All shares of Series 1d Preferred Stock will be converted into 44,777 shares of Common Stock of the Issuer upon consummation of the IPO. The conversion ratio reflects the Stock Split. The Series 1a Preferred Stock is convertible into shares of Common Stock in connection with the Issuer's IPO. All shares of Series 1a Preferred Stock will be converted into 12,195 shares of Common Stock of the Issuer upon consummation of the IPO. The conversion ratio reflects the Stock Split. The Series 1b Preferred Stock is convertible into shares of Common Stock in connection with the Issuer's IPO. All shares of Series 1b Preferred Stock will be converted into 20,000 shares of Common Stock of the Issuer upon consummation of the IPO. The conversion ratio reflects the Stock Split. The Series 1c Preferred Stock is convertible into shares of Common Stock in connection with the Issuer's IPO. All shares of Series 1c Preferred Stock will be converted into 174,216 shares of Common Stock of the Issuer upon consummation of the IPO. The conversion ratio reflects the Stock Split. The Series 1 Preferred Stock is convertible into shares of Common Stock in connection with the Issuer's IPO. All shares of Series 1 Preferred Stock will be converted into 27,103 shares of Common Stock of the Issuer upon consummation of the IPO. The conversion ratio reflects the Stock Split. The Series 1a Preferred Warrants are convertible into warrants to purchase Common Stock in connection with the Issuer's IPO. All Series 1a Preferred Warrants will be converted into warrants exercisable at $20.50 per share, to purchase up to 3,048 shares of Common Stock of the Issuer upon consummation of the IPO. The conversion ratio and exercise price reflect the Stock Split. Reporting person disclaims beneficial ownership of these securities except to the extent of their pecuniary interest therein, and the inclusion of these shares in this report shall not be deemed an admission of beneficial ownership of all of the reported shares for purposes of Section 16 or for any other purpose. Exhibit 24- Power of Attorney /s/ Gerald T. Proehl, Attorney-in Fact 2021-08-12 EX-24 2 poa.htm POWER OF ATTORNEY

POWER OF ATTORNEY

Know all by these present that the undersigned hereby constitutes and appoints each of Gerald T. Proehl, Daniel Porco and Steven Skolnick as their true and lawful attorney-in-fact to:

execute for and on behalf of the undersigned Schedules 13D and 13G and Forms 3, 4 and 5 in accordance with Sections 13 and 16(a) of the Securities Exchange Act of 1934 (the “Exchange Act”) and the rules thereunder;

do and perform any and all acts for and on behalf of the undersigned which may be necessary or desirable to complete the execution of any such Schedules 13D or 13G, Form ID application for EDGAR codes, and Forms 3, 4 or 5, and the timely filing of such Forms with the United States Securities and Exchange Commission and any other authority; and

take any other action of any type whatsoever in connection with the foregoing which, in the opinion of such attorney-in-fact, may be of benefit to, in the best interest of, or legally required by, the undersigned, including, without limitation, the execution and filing of a Form 4 with respect to a transaction which may be reported on a Form 5, it being understood that the documents executed by such attorney-in-fact on behalf of the undersigned pursuant to this Power of Attorney shall be in such form and shall contain such terms and conditions as such attorney-in-fact may approve in his discretion.

The undersigned hereby grants to each such attorney-in-fact full power and authority to do and perform all and every act and thing whatsoever requisite, necessary and proper to be done in the exercise of any of the rights and powers herein granted, as fully and to all intents and purposes as he might or could do in person, with full power of substitution and resubstitution, hereby ratifying and confirming all that such attorney-in-fact, or his substitute or substitutes, shall lawfully do or cause to be done by virtue of this Power of Attorney and the rights and powers herein granted. The undersigned acknowledges that the foregoing attorneys-in-fact, in serving in such capacity at the request of the undersigned, are not assuming any of the undersigned's responsibilities to comply with Sections 13 and 16 of the Exchange Act.

This Power of Attorney shall remain in full force and effect until the undersigned is no longer required to file any Schedules 13D and 13G and Forms 3, 4 and 5 in accordance with Sections 13 and 16(a) of the Exchange Act and the rules thereunder with respect to the undersigned's holdings of and transactions in securities issued by Dermata Therapeutics, Inc. unless earlier revoked by the undersigned in a signed writing delivered to the foregoing attorneys-in-fact.

IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be executed as of June 9, 2021.

/s/ David Hale