0000899243-19-024078.txt : 20190923 0000899243-19-024078.hdr.sgml : 20190923 20190923214323 ACCESSION NUMBER: 0000899243-19-024078 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20190923 FILED AS OF DATE: 20190923 DATE AS OF CHANGE: 20190923 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: MNAYMNEH SAMI CENTRAL INDEX KEY: 0001050046 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39049 FILM NUMBER: 191109077 MAIL ADDRESS: STREET 1: 1001 SOUTH BAYSHORE DRIVE STREET 2: STE 2708 CITY: MIAMI STATE: FL ZIP: 33131 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: TAMER ANTHONY CENTRAL INDEX KEY: 0001050045 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39049 FILM NUMBER: 191109078 MAIL ADDRESS: STREET 1: 1001 SOUTH BAYSHORE DRIVE STREET 2: STE 2708 CITY: MIAMI STATE: FL ZIP: 33131 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: H.I.G.-GPII, Inc. CENTRAL INDEX KEY: 0001788482 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39049 FILM NUMBER: 191109079 BUSINESS ADDRESS: STREET 1: C/O EXAGEN INC. STREET 2: 1261 LIBERTY WAY, SUITE C CITY: VISTA STATE: CA ZIP: 92081 BUSINESS PHONE: (760) 560-1501 MAIL ADDRESS: STREET 1: C/O EXAGEN INC. STREET 2: 1261 LIBERTY WAY, SUITE C CITY: VISTA STATE: CA ZIP: 92081 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: H.I.G. Bio-Exagen, L.P. CENTRAL INDEX KEY: 0001788396 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39049 FILM NUMBER: 191109080 BUSINESS ADDRESS: STREET 1: C/O EXAGEN INC. STREET 2: 1261 LIBERTY WAY, SUITE C CITY: VISTA STATE: CA ZIP: 92081 BUSINESS PHONE: (760) 560-1501 MAIL ADDRESS: STREET 1: C/O EXAGEN INC. STREET 2: 1261 LIBERTY WAY, SUITE C CITY: VISTA STATE: CA ZIP: 92081 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: EXAGEN INC. CENTRAL INDEX KEY: 0001274737 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-MEDICAL LABORATORIES [8071] IRS NUMBER: 000000000 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 1261 LIBERTY WAY CITY: VISTA STATE: CA ZIP: 92081 BUSINESS PHONE: (760) 560-1501 MAIL ADDRESS: STREET 1: 1261 LIBERTY WAY CITY: VISTA STATE: CA ZIP: 92081 FORMER COMPANY: FORMER CONFORMED NAME: EXAGEN DIAGNOSTICS INC DATE OF NAME CHANGE: 20031230 4 1 doc4.xml FORM 4 SUBMISSION X0306 4 2019-09-23 0 0001274737 EXAGEN INC. XGN 0001788396 H.I.G. Bio-Exagen, L.P. 1450 BRICKELL AVENUE, 31ST FLOOR MIAMI FL 33131 0 0 1 0 0001788482 H.I.G.-GPII, Inc. 1450 BRICKELL AVENUE, 31ST FLOOR MIAMI FL 33131 0 0 1 0 0001050045 TAMER ANTHONY 1450 BRICKELL AVENUE, 31ST FLOOR MIAMI FL 33131 0 0 1 0 0001050046 MNAYMNEH SAMI 1450 BRICKELL AVENUE, 31ST FLOOR MIAMI FL 33131 0 0 1 0 Common Stock 2019-09-23 4 C 0 1271252 0.00 A 1271252 I See footnote Common Stock 2019-09-23 4 P 0 425000 14.00 A 1696252 I See footnote Series H Redeemable Convertible Preferred Stock 2019-09-23 4 C 0 233446519 D Common Stock 1271252 0 I See footnote The shares reported on this form are held of record by H.I.G. Bio-Exagen, L.P. ("H.I.G."). H.I.G.-GPII, Inc. ("H.I.G. GP") is the general partner of H.I.G. and has sole voting and investment control over the shares owned by H.I.G. Anthony Tamer and Sami Mnaymneh are the sole shareholders of H.I.G. GP and may be deemed to share beneficial ownership of the shares held by H.I.G. Bio-Exagen, L.P. Each of Mr. Tamer and Mr. Mnaymneh disclaims beneficial ownership of the shares reported herein except to the extent of their pecuniary interest, if any. The Series H Redeemable Convertible Preferred Stock ("Series H") is convertible into the Issuer's Common Stock on a 183.635-for-one basis at the holder's election and has no expiration date. The Series H automatically converted into Common Stock upon the closing of the Issuer's initial public offering. H.I.G. Bio-Exagen, L.P., By: H.I.G.-GPII, Inc., its general partner, /s/ Richard Siegel, Name: Richard Siegel, Title: Authorized Signatory 2019-09-23 H.I.G.-GPII, Inc., By: H.I.G.-GPII, Inc., its general partner, /s/ Richard Siegel, Name: Richard Siegel, Title: Authorized Signatory 2019-09-23 /s/ Anthony Tamer 2019-09-23 /s/ Sami Mnaymneh 2019-09-23