0000899243-19-024081.txt : 20190923 0000899243-19-024081.hdr.sgml : 20190923 20190923214511 ACCESSION NUMBER: 0000899243-19-024081 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20190919 FILED AS OF DATE: 20190923 DATE AS OF CHANGE: 20190923 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: TULLIS JAMES L L CENTRAL INDEX KEY: 0001230641 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39049 FILM NUMBER: 191109082 MAIL ADDRESS: STREET 1: 100 FIRST STAMFORD PLACE CITY: STAMFORD STATE: CT ZIP: 06907 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 2019-09-19 0 0001274737 EXAGEN INC. XGN 0001230641 TULLIS JAMES L L 11770 US HIGHWAY ONE, SUITE 503 PALM BEACH GARDENS FL 33408 1 0 1 0 Common Stock 2019-09-19 4 X 0 11498 14.3235 A 11597 I See footnote Common Stock 2019-09-19 4 F 0 8865 18.58 D 2732 I See footnote Common Stock 2019-09-23 4 C 0 41591 0.00 A 41592 D Common Stock 2019-09-23 4 C 0 1431 0.00 A 1431 I By Spouse Common Stock 2019-09-23 4 C 0 4537 0.00 A 4537 I By Trust Common Stock 2019-09-23 4 C 0 1786853 0.00 A 1789585 I See footnote Warrants 14.3235 2019-09-19 4 X 0 11498 14.3235 D Common Stock 11498 0 I See footnotes Series A-3 Redeemable Convertible Preferred Stock 2019-09-23 4 C 0 468321 D Common Stock 2550 0 I See footnotes Series C Redeemable Convertible Preferred Stock 2019-09-23 4 C 0 5446902 D Common Stock 95069 0 I See footnotes Series E Redeemable Convertible Preferred Stock 2019-09-23 4 C 0 53251030 D Common Stock 929432 0 I See footnotes Series F Redeemable Convertible Preferred Stock 2019-09-23 4 C 0 6895096 D Common Stock 37547 0 D Series F Redeemable Convertible Preferred Stock 2019-09-23 4 C 0 262821 D Common Stock 1431 0 I By Spouse Series F Redeemable Convertible Preferred Stock 2019-09-23 4 C 0 833333 D Common Stock 4537 0 I By Trust Series F Redeemable Convertible Preferred Stock 2019-09-23 4 C 0 81166226 D Common Stock 441998 0 I See footnotes Series H Redeemable Convertible Preferred Stock 2019-09-23 4 C 0 742761 D Common Stock 4045 0 D Series H Redeemable Convertible Preferred Stock 2019-09-23 4 C 0 58359932 D Common Stock 317804 0 I See footnotes The shares reported on this form are held of record by Tullis-Dickerson Capital Focus III, L.P. ("Tullis"), Tullis Growth Fund, L.P. ("Tullis Growth") and Tullis Growth Fund II, L.P. ("Tullis Growth II"). Tullis-Dickerson Partners III, LLC ("Tullis Partners") is the general partner of Tullis and may be deemed to beneficially own the securities held by Tullis. Tullis Growth Partners, LLC and Tullis Growth Partners II, LLC are the general partners of Tullis Growth and Tullis Growth II, respectively, and may be deemed to beneficially own the securities held by Tullis Growth and Tullis Growth II. James L.L. Tullis is a Principal of each of the foregoing entities and may be deemed to possess voting and investment control over, and may be deemed to have an indirect beneficial ownership with respect to, the shares held by Tullis, Tullis Growth and Tullis Growth II. Represents securities held of record by Tullis. The warrants are currently exercisable and will terminate upon closing of the Issuer's initial public offering. Represents warrants that previously entitled the holders to purchase Series E Redeemable Convertible Preferred Stock, which, pursuant to their terms, were settled in shares of the Issuer's Common Stock. Includes warrants held by Tullis and Tullis Growth, respectively, to purchase 43 shares of the Issuer's Common Stock and warrants to purchase 11,455 shares of the Issuer's Common Stock. The Series A-3 Redeemable Convertible Preferred Stock (the "Series A-3") 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 A-3 automatically converted into Common Stock upon the closing of the Issuer's initial public offering. The Series C Redeemable Convertible Preferred Stock (the "Series C") is convertible into the Issuer's Common Stock on a 57.294-for-one basis at the holder's election and has no expiration date. The Series C automatically converted into Common Stock upon the closing of the Issuer's initial public offering. The Series E Redeemable Convertible Preferred Stock (the "Series E") is convertible into the Issuer's Common Stock on a 57.294-for-one basis at the holder's election and has no expiration date. The Series E automatically converted into Common Stock upon the closing of the Issuer's initial public offering. Includes 656,282 and 273,150 shares of common stock underlying the Series E shares held by Tullis and Tullis Growth, respectively. The Series F Redeemable Convertible Preferred Stock ("Series F") 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 F automatically converted into Common Stock upon the closing of the Issuer's initial public offering. Includes 242,226 and 199,771 shares of common stock underlying the Series F shares held by Tullis and Tullis Growth, respectively. 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. Includes 106,897 shares, 105,453 shares and 105,453 shares of common stock underlying the Series H shares held by Tullis, Tullis Growth and Tullis Growth II, respectively. /s/ James L.L. Tullis 2019-09-23