SEC Form 4
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*
Omega Fund V, L.P.

(Last) (First) (Middle)
888 BOYLSTON STREET, SUITE 1111

(Street)
BOSTON MA 02199

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
Trevi Therapeutics, Inc. [ TRVI ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director X 10% Owner
Officer (give title below) Other (specify below)
3. Date of Earliest Transaction (Month/Day/Year)
05/09/2019
4. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
Form filed by One Reporting Person
X Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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 05/09/2019 C 582,408 A (1) 582,408 D(2)
Common Stock 05/09/2019 P 481,000 A $10 1,063,408 D(2)
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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 C Preferred Stock (1) 05/09/2019 C 5,136,986 (1) (1) Common Stock 582,408 $0.00 0 D(2)
1. Name and Address of Reporting Person*
Omega Fund V, L.P.

(Last) (First) (Middle)
888 BOYLSTON STREET, SUITE 1111

(Street)
BOSTON MA 02199

(City) (State) (Zip)
1. Name and Address of Reporting Person*
Omega Fund V GP, L.P.

(Last) (First) (Middle)
888 BOYLSTON STREET, SUITE 1111

(Street)
BOSTON MA 02199

(City) (State) (Zip)
1. Name and Address of Reporting Person*
Omega Fund V GP Manager, Ltd.

(Last) (First) (Middle)
888 BOYLSTON STREET, SUITE 1111

(Street)
BOSTON MA 02199

(City) (State) (Zip)
1. Name and Address of Reporting Person*
Mitsak Anna Guyer

(Last) (First) (Middle)
888 BOYLSTON STREET, SUITE 1111

(Street)
BOSTON MA 02199

(City) (State) (Zip)
Explanation of Responses:
1. On May 9, 2019, the Series C Preferred Stock, and the dividends that had accrued thereon to date, converted into Common Stock on a 9.5-for-one basis without payment of further consideration automatically upon the closing of the Issuer's initial public offering. The shares had no expiration date.
2. The reported securities are held directly by Omega Fund V, L.P. ("Omega V"). The reported securities may be deemed to be beneficially owned by each of Omega Fund V GP, L.P. ("Omega V GP"), as the general partner of Omega V, and Omega Fund V GP Manager, Ltd. ("Omega V GP Manager"), as the general partner of Omega V GP. Otello Stampacchia, Richard Lim, Anne-Mari Paster and Claudio Nessi (the "Omega Directors") are all the shareholders and directors of Omega V GP Manager and have shared voting and investment power over the shares held by Omega V. Annie Mitsak, a member of the Issuer's board of directors, has no voting or investment control over any of the shares held by Omega V. Each of Omega V GP, Omega Fund V GP Manager, the Omega Directors and Annie Mitsak disclaims beneficial ownership of the securities reported herein, except to the extent of its or their pecuniary interest therein, if any.
Remarks:
By: Omega Fund V, L.P., By: Omega Fund GP, L.P., its General Partner, By: Omega Fund V GP Manager, Ltd., its General Partner, /s/ Anne-Mari Paster, Director 05/09/2019
By: Omega Fund GP, L.P., By: Omega Fund V GP Manager, Ltd., its General Partner, /s/ Anne-Mari Paster, Director 05/09/2019
By: Omega Fund V GP Manager, Ltd., its General Partner, /s/ Anne-Mari Paster, Director 05/09/2019
/s/ Annie Mitsak 05/09/2019
** 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).
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