0001019687-14-000490.txt : 20140212 0001019687-14-000490.hdr.sgml : 20140212 20140212192531 ACCESSION NUMBER: 0001019687-14-000490 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20140211 FILED AS OF DATE: 20140212 DATE AS OF CHANGE: 20140212 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Eleven Biotherapeutics, Inc. CENTRAL INDEX KEY: 0001485003 STANDARD INDUSTRIAL CLASSIFICATION: PHARMACEUTICAL PREPARATIONS [2834] IRS NUMBER: 252025616 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 215 FIRST STREET STREET 2: SUITE 400 CITY: CAMBRIDGE STATE: MA ZIP: 02142 BUSINESS PHONE: 617-871-9911 MAIL ADDRESS: STREET 1: 215 FIRST STREET STREET 2: SUITE 400 CITY: CAMBRIDGE STATE: MA ZIP: 02142 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: JAFCO Super V3 Investment Limited Partnership CENTRAL INDEX KEY: 0001590442 STATE OF INCORPORATION: M0 FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-36296 FILM NUMBER: 14602297 BUSINESS ADDRESS: STREET 1: OTEMACHI FIRST SQUARE, WEST TOWER 11F STREET 2: 1-5-1 OTEMACHI CITY: CHIYODA-KU, TOKYO 100-0004 STATE: M0 ZIP: 100-0004 BUSINESS PHONE: 81-3-5223-7008 MAIL ADDRESS: STREET 1: OTEMACHI FIRST SQUARE, WEST TOWER 11F STREET 2: 1-5-1 OTEMACHI CITY: CHIYODA-KU, TOKYO 100-0004 STATE: M0 ZIP: 100-0004 4 1 jafco_f4.xml OWNERSHIP DOCUMENT X0306 4 2014-02-11 0 0001485003 Eleven Biotherapeutics, Inc. EBIO 0001590442 JAFCO Super V3 Investment Limited Partnership OTEMACHI FIRST SQUARE, WEST TOWER 11F, 1-5-1, OTENACHI CHIYODA-KU TOKYO, JAPAN M0 100-0004 JAPAN 0 0 1 0 Common Stock 2014-02-11 4 P 0 219790 10 A 219790 D Common Stock 2014-02-11 4 C 0 1574803 A 1794593 D Common Stock 2014-02-11 4 C 0 232105 A 2026698 D Common Stock 2014-02-11 4 M 0 60853 A 2087551 D Common Stock 2014-02-11 4 M 0 39740 A 2127291 D Series A Preferred Stock 2014-02-11 4 C 0 1574803 0.00 D Common Stock 1574803 0 D Series B Preferred Stock 2014-02-11 4 C 0 232105 0.00 D Common Stock 232105 0 D Common Stock Warrant (right to purchase) 2014-02-11 4 M 0 61242 0.00 D Common Stock 60853 0 D Common Stock Warrant (right to purchase) 2014-02-11 4 M 0 39994 0.00 D Common Stock 39740 0 D The aggregate number of shares of Issuer's Preferred Stock held by the Reporting Person converted into Common Stock immediately prior to the closing of the Issuer's initial public offering and has no expiration date. These shares converted into Common Stock on a 1-for-1 basis. The Reporting Person exercised warrants to purchase shares of Common Stock by cashless exercise immediately prior to the closing of the Issuer's initial public offering. /s/ Hironori Hozoji 2014-02-12