0001209191-18-040426.txt : 20180702 0001209191-18-040426.hdr.sgml : 20180702 20180702171414 ACCESSION NUMBER: 0001209191-18-040426 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20180702 FILED AS OF DATE: 20180702 DATE AS OF CHANGE: 20180702 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Clarus Lifesciences III, L.P. CENTRAL INDEX KEY: 0001597143 STATE OF INCORPORATION: DE FISCAL YEAR END: 1214 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38554 FILM NUMBER: 18933687 BUSINESS ADDRESS: STREET 1: 101 MAIN STREET STREET 2: SUITE 1210 CITY: CAMBRIDGE STATE: MA ZIP: 02142 BUSINESS PHONE: 617-949-2200 MAIL ADDRESS: STREET 1: 101 MAIN STREET STREET 2: SUITE 1210 CITY: CAMBRIDGE STATE: MA ZIP: 02142 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Clarus Ventures III GP, L.P. CENTRAL INDEX KEY: 0001620148 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38554 FILM NUMBER: 18933688 BUSINESS ADDRESS: STREET 1: C/O CLARUS VENTURES STREET 2: 101 MAIN STREET, SUITE 1210 CITY: CAMBRIDGE STATE: MA ZIP: 02142 BUSINESS PHONE: 617-949-2200 MAIL ADDRESS: STREET 1: C/O CLARUS VENTURES STREET 2: 101 MAIN STREET, SUITE 1210 CITY: CAMBRIDGE STATE: MA ZIP: 02142 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Clarus Ventures III, LLC CENTRAL INDEX KEY: 0001664942 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38554 FILM NUMBER: 18933689 BUSINESS ADDRESS: STREET 1: 101 MAIN STREET STREET 2: SUITE 1210 CITY: CAMBRIDGE STATE: MA ZIP: 02142 BUSINESS PHONE: 6179492200 MAIL ADDRESS: STREET 1: 101 MAIN STREET STREET 2: SUITE 1210 CITY: CAMBRIDGE STATE: MA ZIP: 02142 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: HENNER DENNIS CENTRAL INDEX KEY: 0001249153 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38554 FILM NUMBER: 18933690 MAIL ADDRESS: STREET 1: THE JOHN HANCOCK TOWER STREET 2: 200 CLARENDON STREET, 54TH FLOOR CITY: BOSTON STATE: MA ZIP: 02116 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: GALAKATOS NICHOLAS CENTRAL INDEX KEY: 0001252522 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38554 FILM NUMBER: 18933691 MAIL ADDRESS: STREET 1: THE JOHN HANCOCK TOWER STREET 2: 200 CLARENDON STREET, 54TH FLOOR CITY: BOSTON STATE: MA ZIP: 02116 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: LIPTAK ROBERT CENTRAL INDEX KEY: 0001252523 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38554 FILM NUMBER: 18933692 MAIL ADDRESS: STREET 1: THE JOHN HANCOCK TOWER STREET 2: 200 CLARENDON STREET, 54TH FLOOR CITY: BOSTON STATE: MA ZIP: 02116 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Simon Nicholas CENTRAL INDEX KEY: 0001431403 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38554 FILM NUMBER: 18933693 MAIL ADDRESS: STREET 1: 101 MAIN STREET SUITE 1210 CITY: CAMBRIDGE STATE: MA ZIP: 02142 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Requadt Scott CENTRAL INDEX KEY: 0001664852 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38554 FILM NUMBER: 18933694 MAIL ADDRESS: STREET 1: 101 MAIN STREET, SUITE 1210 CITY: CAMBRIDGE STATE: MA ZIP: 02142 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: WHEELER KURT CENTRAL INDEX KEY: 0001252525 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38554 FILM NUMBER: 18933695 MAIL ADDRESS: STREET 1: 801 GATEWAY BLVD STREET 2: STE 410 CITY: SAN FRANCISCO STATE: CA ZIP: 94080 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Forty Seven, Inc. CENTRAL INDEX KEY: 0001667633 STANDARD INDUSTRIAL CLASSIFICATION: PHARMACEUTICAL PREPARATIONS [2834] IRS NUMBER: 474065674 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 1490 O'BRIEN DRIVE, SUITE A CITY: MENLO PARK STATE: CA ZIP: 94025 BUSINESS PHONE: (650) 352-4150 MAIL ADDRESS: STREET 1: 1490 O'BRIEN DRIVE, SUITE A CITY: MENLO PARK STATE: CA ZIP: 94025 4 1 doc4.xml FORM 4 SUBMISSION X0306 4 2018-07-02 0 0001667633 Forty Seven, Inc. FTSV 0001597143 Clarus Lifesciences III, L.P. 101 MAIN STREET, 12TH FLOOR CAMBRIDGE MA 02142 0 0 1 0 0001620148 Clarus Ventures III GP, L.P. 101 MAIN STREET, 12TH FLOOR CAMBRIDGE MA 02142 0 0 1 0 0001664942 Clarus Ventures III, LLC 101 MAIN STREET, 12TH FLOOR CAMBRIDGE MA 02142 0 0 1 0 0001249153 HENNER DENNIS 101 MAIN STREET, 12TH FLOOR CAMBRIDGE MA 02142 1 0 1 0 0001252522 GALAKATOS NICHOLAS 101 MAIN STREET, 12TH FLOOR CAMBRIDGE MA 02142 0 0 1 0 0001252523 LIPTAK ROBERT 101 MAIN STREET, 12TH FLOOR CAMBRIDGE MA 02142 0 0 1 0 0001431403 Simon Nicholas 101 MAIN STREET, 12TH FLOOR CAMBRIDGE MA 02142 0 0 1 0 0001664852 Requadt Scott 101 MAIN STREET, 12TH FLOOR CAMBRIDGE MA 02142 0 0 1 0 0001252525 WHEELER KURT 101 MAIN STREET, 12TH FLOOR CAMBRIDGE MA 02142 0 0 1 0 Common Stock 2018-07-02 4 C 0 938489 A 938489 I See foonote Common Stock 2018-07-02 4 C 0 755780 A 1694269 I See footnote Common Stock 2018-07-02 4 C 0 1922682 A 3616951 I See footnote Common Stock 2018-07-02 4 P 0 200000 16.00 A 3816951 I See footnote Series A-1 Preferred Stock 2018-07-02 4 C 0 938489 D Common Stock 938489 0 I See footnote Series A-2 Preferred Stock 2018-07-02 4 C 0 755780 D Common Stock 755780 0 I See foonote Series B Preferred Stock 2018-07-02 4 C 0 1922682 D Common Stock 1922682 0 I See footnote The Issuer's preferred stock automatically converted into an equal number of shares of Issuer's common stock immediately upon the closing of the Issuer's initial public offering and has no expiration date. Clarus Ventures III GP, LP, or GPLP, as the sole general partner of Clarus Lifesciences III, LP, or Clarus, may be deemed to beneficially own certain of the shares held by Clarus. GPLP disclaims beneficial ownership of all shares held by Clarus in which the GPLP does not have a pecuniary interest. Clarus Ventures III, LLC, or GPLLC, as the sole general partner of the GPLP, may be deemed to beneficially own certain of the shares held by Clarus. GPLLC disclaims beneficial ownership of all shares held by Clarus in which it does not have an actual pecuniary interest. Each of Dennis Henner, Nicholas Galakatos, Robert Liptak, Nicholas Simon, Scott Requadt and Kurt Wheeler, as individual managing directors of GPLLC, may be deemed to beneficially own certain of the shares held of record by Clarus. Dr. Henner and Messrs. Galakatos, Liptak, Simon, Requadt and Wheeler disclaims beneficial ownership of all shares held of record by Clarus in which they do not have an actual pecuniary interest. Clarus Lifesciences III, L.P., by Clarus Ventures III GP, LP, its general partner, by Clarus Ventures III LLC, its general partner, /s/ Robert Liptak, Managing Director 2018-07-02 Clarus Ventures III GP, L.P., by Clarus Ventures III LLC, its general partner, /s/ Robert Liptak, Managing Director 2018-07-02 Clarus Ventures III LLC, /s/ Robert Liptak, Managing Director 2018-07-02 /s/ Dennis J. Henner 2018-07-02 /s/ Nicholas Galakatos 2018-07-02 /s/ Robert Liptak 2018-07-02 /s/ Nicholas Simon 2018-07-02 /s/ Scott Requadt 2018-07-02 /s/ Kurt Wheeler 2018-07-02