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
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OMB APPROVAL |
OMB Number: |
3235-0104 |
Estimated average burden |
hours per response: |
0.5 |
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1. Name and Address of Reporting Person*
755 PAGE MILL ROAD, SUITE A-200 |
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(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 06/27/2018
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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)
X |
Director |
X |
10% Owner |
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Officer (give title below) |
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Other (specify below) |
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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)
X |
Form filed by One Reporting Person |
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Form filed by More than One Reporting Person |
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Table I - Non-Derivative Securities Beneficially Owned |
1. Title of Security (Instr.
4)
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2.
Amount of Securities Beneficially Owned (Instr.
4)
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3. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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4. Nature of Indirect Beneficial Ownership (Instr.
5)
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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)
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2. Date Exercisable and Expiration Date
(Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr.
4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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6. Nature of Indirect Beneficial Ownership (Instr.
5)
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Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
Stock Option (right to buy) |
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04/26/2028 |
Common Stock |
20,645
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8.7575 |
D
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Series A-1 Preferred Stock |
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Common Stock |
68,530 |
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I |
By Ltd Partnership (NEST)
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Series A-2 Preferred Stock |
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Common Stock |
73,159 |
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I |
By Ltd Partnership (NEST)
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Series B Preferred Stock |
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Common Stock |
73,686 |
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I |
By Ltd Partnership (NEST)
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Series A-1 Preferred Stock |
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Common Stock |
1,052,146 |
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I |
By Ltd Partnership (SHV)
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Series A-2 Preferred Stock |
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Common Stock |
774,165 |
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I |
By Ltd Partnership (SHV)
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Series B Preferred Stock |
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Common Stock |
945,326 |
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I |
By Ltd Partnership (SHV)
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Series A-1 Preferred Stock |
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Common Stock |
667 |
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I |
By Trust
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Explanation of Responses: |
Remarks: |
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/s/ Robert Yin, by power of attorney |
06/27/2018 |
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** 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/ Jeffrey W. Bird