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