SEC FORM 4

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^*

HALE DAVID F

(Last)

(First)

(Middle)

3525 DEL MAR HEIGHTS RD., #332

(Street)

SAN DIEGO

92130

(City)

(State)

(Zip)

2. Issuer Name and Ticker or Trading Symbol
Dermata Therapeutics, Inc. [ DRMA ]

5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)

X	Director	X	10% Owner
	Officer (give title below)		Other (specify below)

3. Date of Earliest Transaction (Month/Day/Year)
08/17/2021

4. If Amendment, Date of Original Filed (Month/Day/Year)

6. Individual or Joint/Group Filing (Check Applicable Line)

X	Form filed by One Reporting Person
	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)
1. Title of Security (Instr. 3)	2. Transaction Date (Month/Day/Year)	2A. Deemed Execution Date, if any (Month/Day/Year)	Code	V	Amount	(A) or (D)	Price		6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)	7. Nature of Indirect Beneficial Ownership (Instr. 4)
Common Stock	08/17/2021		C		44,777	A	⁽¹⁾	299,411	I	By Hale BioVentures LLC⁽⁷⁾
Common Stock	08/17/2021		C		12,195	A	⁽²⁾	311,606	I	By Hale BioVentures LLC⁽⁷⁾
Common Stock	08/17/2021		C		20,000	A	⁽³⁾	331,606	I	By Hale BioVentures LLC⁽⁷⁾
Common Stock	08/17/2021		C		174,216	A	⁽⁴⁾	505,822	I	By Hale BioVentures LLC⁽⁷⁾
Common Stock	08/17/2021		C		27,103	A	⁽⁵⁾	532,925	I	By Hale BioVentures LLC⁽⁷⁾
Common Stock	08/17/2021		P		35,714	A	⁽⁸⁾	35,714	I	By Hale Family Trust⁽⁷⁾
Common Stock								3,658	D
Common Stock								12,195	I	By Hale Trading Company LP⁽⁷⁾

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)
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)	Code	V	(A)	(D)	Date Exercisable	Expiration Date	Title	Amount or Number of Shares	8. Price of Derivative Security (Instr. 5)		10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)	11. Nature of Indirect Beneficial Ownership (Instr. 4)
Series 1d Preferred Stock	⁽¹⁾	08/17/2021		C			302,112	⁽¹⁾	⁽¹⁾	Common Stock	44,777	$0	0	I	By Hale BioVentures LLC⁽⁷⁾
Series 1a Preferred Stock	⁽²⁾	08/17/2021		C			250,000	⁽²⁾	⁽²⁾	Common Stock	12,195	$0	0	I	By Hale BioVentures LLC⁽⁷⁾
Series 1b Preferred Stock	⁽³⁾	08/17/2021		C			410,000	⁽³⁾	⁽³⁾	Common Stock	20,000	$0	0	I	By Hale BioVentures LLC⁽⁷⁾
Series 1c Preferred Stock	⁽⁴⁾	08/17/2021		C			3,571,428	⁽⁴⁾	⁽⁴⁾	Common Stock	174,216	$0	0	I	By Hale BioVentures LLC⁽⁷⁾
Series 1 Preferred Stock	⁽⁵⁾	08/17/2021		C			555,622	⁽⁵⁾	⁽⁵⁾	Common Stock	27,103	$0	0	I	By Hale BioVentures LLC⁽⁷⁾
Series 1a Warrants	⁽⁶⁾	08/17/2021		C			62,500	11/15/2016	03/14/2026	Common Stock	3,048	$0	0	I	By Hale BioVentures LLC⁽⁷⁾
Warrant to Purchase Common Stock	$20.5	08/17/2021		C		3,048		11/15/2016	03/14/2026	Common Stock	3,048	$0	3,048	I	By Hale BioVentures LLC⁽⁷⁾
Warrant to Purchase Common Stock	$7	08/17/2021		P		35,714		08/17/2021	08/17/2026	Common Stock	35,714	⁽⁸⁾	35,714	I	By Hale Family Trust⁽⁷⁾

Explanation of Responses:

1. The Series 1d Preferred Stock automatically converted into Common Stock of the Issuer upon consummation of the Issuer's initial public offering (the "IPO"). The Series 1d Preferred Stock was convertible at any time and had no expiration date.

2. The Series 1a Preferred Stock converted into Common Stock of the Issuer upon consummation of the IPO. The Series 1a Preferred Stock was convertible at any time and had no expiration date.

3. The Series 1b Preferred Stock converted into Common Stock of the Issuer upon consummation of the IPO. The Series 1b Preferred Stock was convertible at any time and had no expiration date.

4. The Series 1c Preferred Stock converted into Common Stock of the Issuer upon consummation of the IPO. The Series 1c Preferred Stock was convertible at any time and had no expiration date.

5. The Series 1 Preferred Stock converted into Common Stock of the Issuer upon consummation of the IPO. The Series 1 Preferred Stock was convertible at any time and had no expiration date.

6. The Series 1a Preferred Warrants converted into warrants to purchase Common Stock in connection with the IPO.

7. 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.

8. Reporting Person purchased 35,714 Units in the IPO at $7.00 per Unit. Each Unit consists of one share of Common Stock and one warrant to purchase one share of Common Stock.

	/s/ Gerald T. Proehl, Attorney-in-Fact	08/17/2021
	** 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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