0000905718-21-001094.txt : 20210817
0000905718-21-001094.hdr.sgml : 20210817
20210817123851
ACCESSION NUMBER: 0000905718-21-001094
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20210816
FILED AS OF DATE: 20210817
DATE AS OF CHANGE: 20210817
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: PROEHL GERALD T
CENTRAL INDEX KEY: 0001279191
STANDARD INDUSTRIAL CLASSIFICATION: PHARMACEUTICAL PREPARATIONS [2834]
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-40739
FILM NUMBER: 211182008
BUSINESS ADDRESS:
STREET 1: 10590 W OCEAN AIR DR
STREET 2: STE 200
CITY: SAN DIEGO
STATE: CA
ZIP: 92130
BUSINESS PHONE: 8583145700
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
2021-08-16
0
0001853816
Dermata Therapeutics, Inc.
DRMA
0001279191
PROEHL GERALD T
3525 DEL MAR HEIGHTS RD., #332
SAN DIEGO
CA
92130
1
1
1
0
President, CEO and Chairman
Common Stock
2021-08-16
4
P
0
10000
4.9631
A
10000
I
By Proehl Family Trust
Common Stock
2021-08-17
4
C
0
17857
A
17857
I
By Allison Taylor Proehl 2020 Irrevocable Trust
Common Stock
2021-08-17
4
C
0
8928
A
8928
I
By Meghan Proehl Wilder 2020 Irrevocable Trust
Common Stock
2021-08-17
4
C
0
35767
A
35767
I
By Sean Michael Proehl 2020 Irrevocable Trust Dated December 18, 2020
Common Stock
2021-08-17
4
C
0
361147
A
1278464
I
By Proehl Investment Ventures LLC
Common Stock
2021-08-17
4
C
0
111951
A
1390415
I
By Proehl Investment Ventures LLC
Common Stock
2021-08-17
4
C
0
181585
A
1572000
I
By Proehl Investment Ventures LLC
Common Stock
2021-08-17
4
C
0
1247904
A
2819904
I
By Proehl Investment Ventures LLC
Common Stock
2021-08-17
4
C
0
85640
A
2905544
I
By Proehl Investment Ventures LLC
Common Stock
2021-08-17
4
P
0
142857
A
152857
I
By Proehl Family Trust
Common Stock
39512
D
Series 1d Preferred Stock
2021-08-17
4
C
0
120481
0
D
Common Stock
17857
0
I
By Allison Taylor Proehl 2020 Irrevocable Trust
Series 1d Preferred Stock
2021-08-17
4
C
0
60240
0
D
Common Stock
8928
0
I
By Meghan Proehl Wilder 2020 Irrevocable Trust
Series 1d Preferred Stock
2021-08-17
4
C
0
241325
0
D
Common Stock
35767
0
I
By Sean Michael Proehl 2020 Irrevocable Trust Dated December 18, 2020
Series 1d Preferred Stock
2021-08-17
4
C
0
2436657
0
D
Common Stock
361147
0
I
By Proehl Investment Ventures LLC
Series 1a Preferred Stock
2021-08-17
4
C
0
2295000
0
D
Common Stock
111951
0
I
By Proehl Investment Ventures LLC
Series 1b Preferred Stock
2021-08-17
4
C
0
3722500
0
D
Common Stock
181585
0
I
By Proehl Investment Ventures LLC
Series 1c Preferred Stock
2021-08-17
4
C
0
25582050
0
D
Common Stock
1247904
0
I
By Proehl Investment Ventures LLC
Series 1 Preferred Stock
2021-08-17
4
C
0
1755622
0
D
Common Stock
85640
0
I
By Proehl Investment Ventures LLC
Series 1a Warrants
2021-08-17
4
C
0
573750
0
D
2016-11-15
2026-03-14
Common Stock
27987
0
I
By Proehl Investment Ventures LLC
Warrant to Purchase Common Stock
20.50
2021-08-17
4
C
0
27987
0
A
2016-11-15
2026-03-14
Common Stock
27987
27987
I
By Proehl Investment Ventures LLC
Warrant to Purchase Common Stock
7.00
2021-08-17
4
P
0
142857
A
2021-08-17
2026-08-17
Common Stock
142857
142857
I
By Proehl Family Trust
The price reported in Column 4 is a weighted average price. These shares were purchased in multiple transactions at prices ranging from $4.84 to $5.00 per share, inclusive. The Reporting Person undertakes to provide to the Issuer, any security holder of the Issuer, or the staff of the Securities and Exchange Commission, upon request, full information regarding the number of shares purchased at each separate price within the ranges set forth herein.
The Series 1d Preferred Stock automatically 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.
The Series 1a Preferred Stock converted into Common Stock of the Issuer upon consummation of the IPO. The Series 1a Preferred Stock was convertible at any time and had no expiration date.
The Series 1b Preferred Stock converted into Common Stock of the Issuer upon consummation of the IPO. The Series 1b Preferred Stock was convertible at any time and had no expiration date.
The Series 1c Preferred Stock converted into Common Stock of the Issuer upon consummation of the IPO. The Series 1c Preferred Stock was convertible at any time and had no expiration date.
The Series 1 Preferred Stock converted into Common Stock of the Issuer upon consummation of the IPO. The Series 1 Preferred Stock was convertible at any time and had no expiration date.
The Series 1a Preferred Warrants converted into warrants to purchase Common Stock in connection with the IPO.
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.
Reporting Person purchased 142,857 Units in the IPO at $7.00 per Unit Each Unit consists of one share of Common Stock and one warrant to purchase one share of Common Stock.
/s/ Gerald T. Proehl
2021-08-17