SEC Filing | Forty Seven, Inc.

View:

SEC FORM 3 SEC Form 3

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

OMB APPROVAL

OMB Number:			3235-0104
Estimated average burden
hours per response:			0.5

1. Name and Address of Reporting Person^*

WHITE JAMES N

(Last)

(First)

(Middle)

755 PAGE MILL ROAD, SUITE A-200

(Street)

PALO ALTO

94304-1005

(City)

(State)

(Zip)

2. Date of Event Requiring Statement (Month/Day/Year)
06/27/2018

3. Issuer Name and Ticker or Trading Symbol
Forty Seven, Inc. [ FTSV ]

4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)

Director	X	10% Owner
Officer (give title below)		Other (specify below)

5. If Amendment, Date of Original Filed (Month/Day/Year)

6. Individual or Joint/Group Filing (Check Applicable Line)

X	Form filed by One Reporting Person
	Form filed by More than One Reporting Person

Table I - Non-Derivative Securities Beneficially Owned
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)
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)
1. Title of Derivative Security (Instr. 4)	Date Exercisable	Expiration Date	Title	Amount or Number of Shares	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)
Series A-1 Preferred Stock	⁽¹⁾	⁽¹⁾	Common Stock	4,516	⁽¹⁾	D
Series A-1 Preferred Stock	⁽¹⁾	⁽¹⁾	Common Stock	5,161	⁽¹⁾	I	By Irrevocable Trust (ST)⁽²⁾
Series A-1 Preferred Stock	⁽¹⁾	⁽¹⁾	Common Stock	38,173	⁽¹⁾	I	By Ltd Partnership (ROSE)⁽³⁾
Series A-2 Preferred Stock	⁽¹⁾	⁽¹⁾	Common Stock	33,769	⁽¹⁾	I	By Ltd Partnership (ROSE)⁽³⁾
Series B Preferred Stock	⁽¹⁾	⁽¹⁾	Common Stock	40,477	⁽¹⁾	I	By Ltd Partnership (ROSE)⁽³⁾
Series A-1 Preferred Stock	⁽¹⁾	⁽¹⁾	Common Stock	1,052,146	⁽¹⁾	I	By Ltd Partnership (SHV)⁽⁴⁾
Series A-2 Preferred Stock	⁽¹⁾	⁽¹⁾	Common Stock	774,165	⁽¹⁾	I	By Ltd Partnership (SHV)⁽⁴⁾
Series B Preferred Stock	⁽¹⁾	⁽¹⁾	Common Stock	945,326	⁽¹⁾	I	By Ltd Partnership (SHV)⁽⁴⁾
Series A-1 Preferred Stock	⁽¹⁾	⁽¹⁾	Common Stock	587	⁽¹⁾	I	By Trust⁽⁵⁾
Series A-2 Preferred Stock	⁽¹⁾	⁽¹⁾	Common Stock	18,295	⁽¹⁾	I	By Trust⁽⁵⁾
Series B Preferred Stock	⁽¹⁾	⁽¹⁾	Common Stock	11,544	⁽¹⁾	I	By Trust⁽⁵⁾

Explanation of Responses:

1. The issuer's preferred stock will automatically convert into issuer's common stock on a one-to-one basis immediately upon the closing of the issuer's initial public offering and has no expiration date.

2. Shares held by a trust for the benefit of the reporting person of which the reporting person is the sole trustee.

3. Shares held by a limited partnership of which the reporting person is a trustee of a trust which is the general partner. The reporting person disclaims beneficial ownership in these shares except as to the reporting person's pecuniary interest therein.

4. Shares held by Sutter Hill Ventures, a California Limited Partnership. The reporting person is a managing director and member of the management committee of the general partner of Sutter Hill Ventures, a California Limited Partnership. The reporting person disclaims beneficial ownership in these shares except as to the reporting person's pecuniary interest therein.

5. Shares held by a trust of which the reporting person is a trustee. The reporting person disclaims beneficial ownership in these shares except as to the reporting person's pecuniary interest therein.

Remarks:

ftsvjnw.txt

	/s/ Robert Yin, by power of attorney	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.

POWER OF ATTORNEY


	Know all by these presents, that the undersigned hereby authorizes
David E. Sweet, Robert Yin, or Patricia Tom to execute for and on behalf of
the undersigned Forms 3, 4, and 5, and any Amendments thereto for Forty
Seven, Inc. (the "Company"), and cause such form(s) to be filed with the
United States Securities and Exchange Commission pursuant to Section 16(a)
of the Securities Act of 1934, relating to the undersigned's beneficial
ownership of securities in the Company.   The undersigned hereby grants to
each such attorney-in-fact full power and authority to do and perform any
and every act and thing whatsoever requisite, necessary, or proper to be
done in the exercise of any of the rights and powers herein granted, as
fully to all intents and purposes as the undersigned might or could do if
personally present, with full power of substitution or revocation, hereby
ratifying and confirming all that such attorney-in-fact, or such attorney-
in-fact's substitute or substitutes, shall lawfully do or cause to be done
by virtue of this power of attorney and the rights and powers herein granted.
The undersigned acknowledges that the foregoing attorneys-in-fact, in serving
in such a capacity at the request of the undersigned, are not assuming, nor
is the Company assuming, any of the undersigned's responsibilities to comply
with Section 16 of the Securities Exchange Act of 1934.
	This Power of Attorney shall remain in full force and effect until
the undersigned is no longer required to file Forms 3, 4, and 5 with respect
to the undersigned's holdings of, and transactions in, securities issued by
the Company, unless earlier revoked by the undersigned in a signed writing
delivered to the foregoing attorneys-in-fact.
	In witness whereof, the undersigned has caused this Power of Attorney
to be executed as of this 26th day of June, 2018.




                              /s/   James N. White