0000905718-21-001098.txt : 20210817 0000905718-21-001098.hdr.sgml : 20210817 20210817124045 ACCESSION NUMBER: 0000905718-21-001098 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20210817 FILED AS OF DATE: 20210817 DATE AS OF CHANGE: 20210817 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: INSLEY THOMAS CENTRAL INDEX KEY: 0001239545 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-40739 FILM NUMBER: 211182014 MAIL ADDRESS: STREET 1: SKINMEDICA, INC. STREET 2: 5909 SEA LION PLACE, SUITE H CITY: CARLSBAD STATE: CA ZIP: 92010 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 4 1 dermata_fm4aug172021.xml X0306 4 2021-08-17 0 0001853816 Dermata Therapeutics, Inc. DRMA 0001239545 INSLEY THOMAS 3525 DEL MAR HEIGHTS RD., #332 SAN DIEGO CA 92130 0 1 0 0 Chief Financial Officer Common Stock 2021-08-17 4 C 0 4581 A 14337 I By Insley Family Trust Series 1d Preferred Stock 2021-08-17 4 C 0 30910 0 D Common Stock 4581 0 I By Insley Family Trust The Series 1d Preferred Stock 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. 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. /s/ Gerald T. Proehl, Attorney-in-Fact 2021-08-17