0001209191-20-042168.txt : 20200710 0001209191-20-042168.hdr.sgml : 20200710 20200710162708 ACCESSION NUMBER: 0001209191-20-042168 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 2 CONFORMED PERIOD OF REPORT: 20200630 FILED AS OF DATE: 20200710 DATE AS OF CHANGE: 20200710 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: PERRY MICHAEL S CENTRAL INDEX KEY: 0001250379 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-39059 FILM NUMBER: 201023410 MAIL ADDRESS: STREET 1: C/O BIOTRANSPLANT INC STREET 2: 196 BOSTON AVE SUITE 2800 CITY: MEDFORD STATE: MA ZIP: 02155 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Avita Therapeutics, Inc. CENTRAL INDEX KEY: 0001762303 STANDARD INDUSTRIAL CLASSIFICATION: SURGICAL & MEDICAL INSTRUMENTS & APPARATUS [3841] IRS NUMBER: 202578762 STATE OF INCORPORATION: DE FISCAL YEAR END: 0630 BUSINESS ADDRESS: STREET 1: 28159 AVENUE STANFORD STREET 2: SUITE 220 CITY: VALENCIA STATE: CA ZIP: 91355 BUSINESS PHONE: 661-367-9170 MAIL ADDRESS: STREET 1: 28159 AVENUE STANFORD STREET 2: SUITE 220 CITY: VALENCIA STATE: CA ZIP: 91355 FORMER COMPANY: FORMER CONFORMED NAME: Avita Medical, Ltd. DATE OF NAME CHANGE: 20181218 3 1 doc3.xml FORM 3 SUBMISSION X0206 3 2020-06-30 0 0001762303 Avita Therapeutics, Inc. RCEL 0001250379 PERRY MICHAEL S C/O AVITA THERAPEUTICS, INC. 28159 AVENUE STANFORD, SUITE 220 VALENCIA CA 91355 1 1 0 0 Chief Executive Officer Common Stock 348239 D Stock Options (Right to Buy) 5.99 2028-11-30 Common Stock 125000 D Includes 1,266,125 of the Issuer's CHESS Depositary Interests ("CDIs"). CDIs are units of beneficial ownership in shares of common stock of the Issuer that are publicly traded on the Australian Securities Exchange (the "ASX") and held by CHESS Depositary Nominees Pty, Limited, a subsidiary of ASX Limited, the company that operates the ASX. Five CDIs are equivalent to one share of Common Stock and have all the rights and privileges of Common Stock. The Reporting Person holds 1,266,125 CDIs, which translate into 253,225 of the shares of Common Stock set forth above. Includes 95,014 unvested Restricted Stock Units ("RSUs"), each representing a contingent right to be issued one share of Common Stock, that are subject to time-based vesting criteria. These RSUs were originally rights to receive ordinary shares of AVITA Medical, Ltd., an Australian public company and predecessor to the Issuer ("Predecessor"). Pursuant to a scheme of arrangement, completed on June 30, 2020 (the "Scheme"), the RSUs became rights to be issued shares of Common Stock of the Issuer in the ratio of one share of Common Stock for every 100 ordinary shares of Predecessor to which the holder would otherwise have been entitled. The RSUs vest in two equal installments on June 1, 2021 and 2022. These Stock Options were originally exercisable for ordinary shares of Predecessor. Pursuant to the Scheme, the Stock Options became exercisable for shares of Common Stock of the Issuer in the ratio of one share of Common Stock for every 100 ordinary shares of Predecessor for which the Stock Options would otherwise be exercisable. These Stock Options became exercisable based on time-based vesting criteria. The exercise price was converted from A$8.20, which reflects the 100:1 consolidation ratio applied in converting ordinary shares of Predecessor to shares of the Issuer's Common Stock, using the exchange rate as published by the Reserve Bank of Australia in effect on the date of grant (November 30, 2018). The actual exercise price will be the Australian dollar amount regardless of the exchange rate on the date of grant or of exercise. /s/ Donna Shiroma, by power of attorney 2020-07-10 EX-24.3_928591 2 poa.txt POA DOCUMENT POWER OF ATTORNEY (For Executing Form ID and Forms 3, 4 and 5) Know all by these presents, that the undersigned hereby constitutes and appoints Donna Shiroma of AVITA Therapeutics, Inc. (the "Company") and Coleman Wombwell of K&L Gates LLP, signing individually, the undersigned's true and lawful attorneys in fact and agents to: (1) Prepare, execute in the undersigned's name and on the undersigned's behalf, and submit to the Securities and Exchange Commission (the "SEC") a Form ID, Uniform Application for Access Codes to File on EDGAR, including amendments thereto, and any other documents necessary or appropriate to obtain codes and passwords enabling the undersigned to make electronic filings with the SEC of reports required by Section 16(a) of the Securities Exchange Act of 1934, as amended (the "Exchange Act"), or any rule or regulation thereunder; (2) Prepare, execute in the undersigned's name and on the undersigned's behalf, and submit to the SEC Forms 3, 4 and 5 (including amendments thereto and joint filing agreements in connection therewith) in accordance with Section 16(a) of the Exchange Act and the rules thereunder in the undersigned's capacity as an officer, director or beneficial owner of more than 10% of a registered class of securities of the Company; (3) Do and perform any and all acts for and on behalf of the undersigned that may be necessary or desirable to prepare and execute any such Form 3, 4 or 5 (including amendments thereto and joint filing agreements in connection therewith) and file such forms with the SEC and any stock exchange, self-regulatory association or any similar authority; and (4) Take any other action of any type whatsoever in connection with the foregoing that, in the opinion of such attorney-in-fact, may be of benefit to, in the best interest of, or legally required of the undersigned, it being understood that the documents executed by the 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 the attorney-in-fact may approve in the attorney-in-fact's discretion. The undersigned hereby grants to 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 attorney-in-fact, and their substitutes, 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 Exchange Act. 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 Company and 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 K&L Gates LLP, as applicable. IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be executed as of the date written below. Date: June 21, 2020 By: /s/ Michael Perry Name: Michael Perry