0001209191-23-045687.txt : 20230814 0001209191-23-045687.hdr.sgml : 20230814 20230814174253 ACCESSION NUMBER: 0001209191-23-045687 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 2 CONFORMED PERIOD OF REPORT: 20230810 FILED AS OF DATE: 20230814 DATE AS OF CHANGE: 20230814 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: HICKS KERRY R CENTRAL INDEX KEY: 0001110473 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39813 FILM NUMBER: 231172348 MAIL ADDRESS: STREET 1: C/O HEALTHGRADES.COM STREET 2: 44 UNION BLVD SUITE 600 CITY: LAKEOOD STATE: CO ZIP: 80228 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: TriSalus Life Sciences, Inc. CENTRAL INDEX KEY: 0001826667 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-MEDICAL LABORATORIES [8071] IRS NUMBER: 853009869 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 6272 WEST 91ST AVENUE CITY: WESTMINSTER STATE: CO ZIP: 80031 BUSINESS PHONE: 415 336 8917 MAIL ADDRESS: STREET 1: 6272 WEST 91ST AVENUE CITY: WESTMINSTER STATE: CO ZIP: 80031 FORMER COMPANY: FORMER CONFORMED NAME: MedTech Acquisition Corp DATE OF NAME CHANGE: 20200930 3 1 doc3.xml FORM 3 SUBMISSION X0206 3 2023-08-10 0 0001826667 TriSalus Life Sciences, Inc. TLSI 0001110473 HICKS KERRY R 6272 W. 91ST AVENUE WESTMINSTER CO 80031 1 0 0 0 Common Stock 1370028 I By HW Investment Partners, LLC Common Stock 514589 D Common Stock 81845 I By Millennium Trust Company, LLC Common Stock 322737 I By The Kerry Raymond Hicks Dynasty Trust Stock Option (right to buy) 0.41 2031-04-20 Common Stock 1977 D Stock Option (right to buy) 0.41 2031-04-20 Common Stock 4943 D Stock Option (right to buy) 2.43 2032-01-18 Common Stock 12359 D Stock Option (right to buy) 2.43 2032-07-12 Common Stock 4943 D The securities reported herein were acquired by the Reporting Person prior to the Reporting Person becoming a director of the Issuer. The Reporting Person was appointed as a director of the Issuer effective immediately after the effective time of the Merger (as defined in that certain Agreement and Plan of Merger, dated as of November 11, 2022, as amended, by and among the Issuer, MTAC Merger Sub, Inc., and TriSalus Operating Life Sciences, Inc.). The Reporting Person is a managing member of HW Investment Partners, LLC ("HW Investment") and shares voting and investment discretion with respect to the shares held directly by HW Investment. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein. The shares are held directly by Millennium Trust Company, LLC for which the Reporting Person acts as custodian. The Reporting Person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein. The shares are held directly by The Kerry Raymond Hicks Dynasty Trust, for which the Reporting Person serves as trustee. The shares subject to this option shall vest in equal quarterly installments over three years, with 1/12th of the total number of shares subject to the option vesting on each quarterly anniversary of the vesting commencement date, subject to the Reporting Person's continued service with the Issuer on each respective vesting date. The shares subject to this stock option vest in 48 equal monthly installments from the vesting commencement date of March 18, 2021, subject to the Reporting Person's continued service with the Issuer on each respective vesting date. The shares subject to this stock option vest in 48 equal monthly installments from the vesting commencement date of January 19, 2022, subject to the Reporting Person's continued service with the Issuer on each respective vesting date. Twenty-five percent of the shares subject to the option vested on June 17, 2023, the first anniversary of the vesting commencement date, and the remainder vests in 36 equal monthly installments thereafter, subject to the Reporting Person's continued service with the Issuer on each respective vesting date. /s/ Sean Murphy, Attorney-in-Fact for Kerry Hicks 2023-08-14 EX-24 2 poa.txt POA DOCUMENT POWER OF ATTORNEY Know all by these presents, that the undersigned hereby constitutes and appoints each of Mary Szela and Sean Murphy of TriSalus Life Sciences, Inc. (the "Company") and Alla Kagan of Cooley LLP, signing individually, as the undersigned's true and lawful attorneys-in fact and agents to: (1) execute for and on behalf of the undersigned, in the undersigned's capacity as an officer, director and/or greater than 10% stockholder of the Company, Forms 3, 4 and 5 (including any amendments thereto) in accordance with Section 16(a) of the Securities Exchange Act of 1934 and the rules thereunder; (2) do and perform any and all acts for and on behalf of the undersigned which may be necessary or desirable to complete and execute any such Forms 3, 4 or 5 (including any amendments thereto) and timely file such forms with the U.S. Securities and Exchange Commission and any stock exchange or similar authority; and (3) take any other action of any nature 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, 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 such attorney-in-fact's discretion. The undersigned hereby grants to each such attorney-in-fact full power and authority to do and perform any and every act and thing whatsoever requisite, necessary or proper to be done in the exercise of any of the rights and powers herein granted, as fully to all intents and purposes as the undersigned might or could do if personally present, with full power of substitution or revocation, hereby ratifying and confirming all that such attorney-in-fact, or such attorney-in-fact's 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, nor is the Company assuming, any of the undersigned's responsibilities to comply with Section 16 of the Securities Exchange Act of 1934, as amended. This Power of Attorney shall remain in full force and effect until the earliest to occur of (a) the undersigned is no longer required to file Forms 3, 4 and 5 with respect to the undersigned's holdings of and transactions in securities issued by the Company, (b) revocation by the undersigned in a signed writing delivered to the foregoing attorneys-in-fact or (c) as to any attorney-in-fact individually, until such attorney-in-fact is no longer employed by the Company or employed by or a partner at Cooley LLP, as applicable. The undersigned has caused this Power of Attorney to be executed as of July 21, 2023. Kerry Hicks /s/ Kerry Hicks (Signature)