FORM 4 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940 |
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). |
1. Name and Address of Reporting Person*
(Street)
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2. Issuer Name and Ticker or Trading Symbol
VAPOTHERM INC [ VAPO ] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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3. Date of Earliest Transaction
(Month/Day/Year) 11/16/2018 | ||||||||||||||||||||||||||
4. If Amendment, Date of Original Filed
(Month/Day/Year) 01/24/2020 |
6. Individual or Joint/Group Filing (Check Applicable Line)
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned | ||||||||||
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1. Title of Security (Instr. 3) | 2. Transaction Date (Month/Day/Year) | 2A. Deemed Execution Date, if any (Month/Day/Year) | 3. Transaction Code (Instr. 8) | 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) | 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) | 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 7. Nature of Indirect Beneficial Ownership (Instr. 4) | |||
Code | V | Amount | (A) or (D) | Price | ||||||
Common Stock | 11/16/2018 | C | 2,042,595 | A | (1) | 2,042,595 | I | By Vapotherm Investors, LLC(3) | ||
Common Stock | 11/16/2018 | C | 208,752 | A | (2) | 2,251,347 | I | By Vapotherm Investors, LLC(3) | ||
Common Stock | 11/16/2018 | C | 1,049,958 | A | (1) | 1,049,958 | I | By 3x5 Special Opportunity Fund, L.P.(3) |
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||||||||||
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1. Title of Derivative Security (Instr. 3) | 2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) | 6. Date Exercisable and Expiration Date (Month/Day/Year) | 7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4) | 8. Price of Derivative Security (Instr. 5) | 9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) | 10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 11. Nature of Indirect Beneficial Ownership (Instr. 4) | ||||
Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||||||
Series A Convertible Preferred Stock | (1) | 11/16/2018 | C | 227,600 | (1) | (1) | Common Stock | 227,600 | $0.00 | 0 | I | By Vapotherm Investors, LLC(3) | |||
Series B Convertible Preferred Stock | (1) | 11/16/2018 | C | 75,700 | (1) | (1) | Common Stock | 75,700 | $0.00 | 0 | I | By Vapotherm Investors, LLC(3) | |||
Series C Convertible Preferred Stock | (1) | 11/16/2018 | C | 849,239 | (1) | (1) | Common Stock | 849,239 | $0.00 | 0 | I | By Vapotherm Investors, LLC(3) | |||
Series D Convertible Preferred Stock | (1) | 11/16/2018 | C | 890,056 | (1) | (1) | Common Stock | 890,056 | $0.00 | 0 | I | By Vapotherm Investors, LLC(3) | |||
Series D-1 Convertible Preferred Stock | (2) | 11/16/2018 | C | 208,752 | (2) | (2) | Common Stock | 208,752 | $0.00 | 0 | I | By Vapotherm Investors, LLC(3) | |||
Warrant to purchase Series A Convertible Preferred Stock(4) | $14.48 | 11/16/2018 | J(4) | 42,857 | 11/16/2018 | 09/07/2022 | Common Stock(4) | 42,857 | $0.00 | 42,857 | I | By Vapotherm Investors, LLC(3) | |||
Series A Convertible Preferred Stock | (1) | 11/16/2018 | C | 500,000 | (1) | (1) | Common Stock | 500,000 | $0.00 | 0 | I | By 3x5 Special Opportunity Fund, L.P.(3) | |||
Series B Convertible Preferred Stock | (1) | 11/16/2018 | C | 285,714 | (1) | (1) | Common Stock | 285,714 | $0.00 | 0 | I | By 3x5 Special Opportunity Fund, L.P.(3) | |||
Series C Convertible Preferred Stock | (1) | 11/16/2018 | C | 264,244 | (1) | (1) | Common Stock | 264,244 | $0.00 | 0 | I | By 3x5 Special Opportunity Fund, L.P.(3) |
Explanation of Responses: |
1. Upon closing of the Issuer's initial public offering, share of Series A Convertible Preferred Stock, Series B Convertible Preferred Stock, Series C Convertible Preferred Stock and Series D Convertible Preferred Stock automatically converted into one share of Common Stock without payment or further consideration. There was no expiration date for the Series A Convertible Preferred Stock, the Series B Convertible Preferred Stock, the Series C Convertible Preferred Stock or the Series D Convertible Preferred Stock. |
2. Upon closing of the Issuer's initial public offering, each share of Series D-1 Convertible Preferred Stock automatically converted into 1.137 shares of Common Stock without payment or further consideration. There was no expiration date for the Series D-1 Convertible Preferred Stock. |
3. The Reporting Person is a managing member of 3x5 Partners, LLC. 3x5 Partners, LLC is the managing member of Vapotherm Investors, LLC and a member of 3x5 Special Opportunity Partners, LLC, which is the general partner of 3x5 Special Opportunity Fund, L.P., and by virtue of these relationships 3x5 Partners, LLC may be deemed to indirectly beneficially own the shares directly held by Vapotherm Investors, LLC and 3x5 Special Opportunity Partners, L.P. As a managing member of 3x5 Partners, LLC the Reporting Person shares voting and dispositive power over such securities. The Reporting Person disclaims beneficial ownership, within the meaning of Section 16 of the Securities Exchange Act of 1934, as amended, or otherwise, of such securities except to the extent of his pecuniary interest therein. |
4. Immediately prior to the closing of the Issuer's initial public offering, each outstanding Warrant to Purchase Series A Convertible Preferred Stock automatically converted into a Warrant to Purchase Common Stock. |
Remarks: |
/s/ Anthony Ten Haagen, as Attorney-In-Fact | 03/26/2020 | |
** Signature of Reporting Person | Date | |
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | ||
* If the form is filed by more than one reporting person, see Instruction 4 (b)(v). | ||
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). | ||
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. | ||
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. |