FORM 3 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES 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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1. Name and Address of Reporting Person*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 06/27/2018 |
3. Issuer Name and Ticker or Trading Symbol
Forty Seven, Inc. [ FTSV ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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5. If Amendment, Date of Original Filed
(Month/Day/Year) |
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6. Individual or Joint/Group Filing (Check Applicable Line)
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Table I - Non-Derivative Securities Beneficially Owned | |||
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1. Title of Security (Instr. 4) | 2. Amount of Securities Beneficially Owned (Instr. 4) | 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 4. Nature of Indirect Beneficial Ownership (Instr. 5) |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
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1. Title of Derivative Security (Instr. 4) | 2. Date Exercisable and Expiration Date (Month/Day/Year) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 6. Nature of Indirect Beneficial Ownership (Instr. 5) | ||
Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Series A-1 Preferred Stock | (1) | (1) | Common Stock | 67,036 | (1) | I | See footnote(2)(3) |
Series A-1 Preferred Stock | (1) | (1) | Common Stock | 1,340,698 | (1) | I | See footnote(3)(4) |
Series A-2 Preferred Stock | (1) | (1) | Common Stock | 1,133,670 | (1) | I | See footnote(3)(4) |
1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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Explanation of Responses: |
1. The Issuer's preferred stock will automatically convert into an equal number of shares of Issuer's common stock immediately upon the closing of the Issuer's initial public offering and has no expiration date. |
2. Shares held by Lightspeed Affiliates X, L.P., or Lightspeed Affiliates. |
3. Lightspeed General Partner X, L.P., or Lightspeed GP X, is the general partner of Lightspeed X and Lightspeed Affiliates. Lightspeed Ultimate General Partner X, Ltd., or Lightspeed UGP X, is the general partner of Lightspeed GP X. Christopher J. Schaepe, Barry Eggers, Ravi Mhatre, Peter Nieh and Jeremy Liew are the directors of Lightspeed UGP X and share voting and dispositive power with respect to the shares held by Lightspeed X and Lightspeed Affiliates. Messrs. Schaepe, Eggers, Liew, Mhatre and Nieh disclaim beneficial ownership of the shares held by Lightspeed X and Lightspeed Affiliates except to the extent of their pecuniary interest therein. |
4. Shares held by Lightspeed Venture Partners X, L.P., or Lightspeed X. |
Remarks: |
Lightspeed Venture Partners X, L.P., by Lightspeed General Partner X, L.P., its general partner, by Lightspeed Ultimate General Partner X, Ltd., its general partner, /s/ Christopher J. Schaepe, Duly authorized signatory | 06/27/2018 | |
Lightspeed Affiliates X, L.P., by Lightspeed General Partner X, L.P., its general partner, by Lightspeed Ultimate General Partner X, Ltd., its general partner, /s/ Christopher J. Schaepe, Duly authorized signatory | 06/27/2018 | |
Lightspeed General Partner X, L.P., by Lightspeed Ultimate General Partner X, Ltd., its general partner, /s/ Christopher J. Schaepe, Duly authorized signatory | 06/27/2018 | |
Lightspeed Ultimate General Partner X, Ltd., /s/ Christopher J. Schaepe, Duly authorized signatory | 06/27/2018 | |
/s/ Christopher J. Schaepe | 06/27/2018 | |
/s/ Barry Eggers | 06/27/2018 | |
/s/ Peter Nieh | 06/27/2018 | |
/s/ Ravi Mhatre | 06/27/2018 | |
/s/ Jeremy Liew | 06/27/2018 | |
** 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 5 (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). | ||
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. | ||
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. |