0001415889-21-004876.txt : 20211015 0001415889-21-004876.hdr.sgml : 20211015 20211015144306 ACCESSION NUMBER: 0001415889-21-004876 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20211013 FILED AS OF DATE: 20211015 DATE AS OF CHANGE: 20211015 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Stevens David R CENTRAL INDEX KEY: 0001292382 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-35182 FILM NUMBER: 211325786 MAIL ADDRESS: STREET 1: 300 ELLIOTT AVENUE WEST STREET 2: SUITE 500 CITY: SEATTLE STATE: WA ZIP: 98119-4114 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Ampio Pharmaceuticals, Inc. CENTRAL INDEX KEY: 0001411906 STANDARD INDUSTRIAL CLASSIFICATION: PHARMACEUTICAL PREPARATIONS [2834] IRS NUMBER: 260179592 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 373 INVERNESS PARKWAY STREET 2: SUITE 200 CITY: ENGLEWOOD STATE: CO ZIP: 80112 BUSINESS PHONE: 720-437-6500 MAIL ADDRESS: STREET 1: 373 INVERNESS PARKWAY STREET 2: SUITE 200 CITY: ENGLEWOOD STATE: CO ZIP: 80112 FORMER COMPANY: FORMER CONFORMED NAME: Chay Enterprises, Inc. DATE OF NAME CHANGE: 20070910 4 1 form4-10152021_111058.xml X0306 4 2021-10-13 0001411906 Ampio Pharmaceuticals, Inc. AMPE 0001292382 Stevens David R C/O AMPIO PHARMACEUTICALS, INC. 373 INVERNESS PARKWAY, SUITE 200 ENGLEWOOD CO 80112 true false false false Stock Option (Right to Buy) 1.67 2021-10-13 4 A 0 120000 0 A 2031-10-13 Common Stock 120000 120000 D The options vest as follows: 50% on the grant date and 50% on March 31, 2022. /s/ Daniel Stokely, Attorney-in-Fact 2021-10-15