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