SEC Form 4 · accession 0000899243-18-028080

Axonics Modulation Technologies, Inc. · AXNX

Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗

Reporting owners

Other

Other

Period of report

Nov 2, 2018

Accepted (ET)

Nov 2, 2018 · 7:26 pm EDT

Rule 10b5-1 plan

unknown — predates the checkbox

Issuer CIK

0001603756

Table I — non-derivative securities

Security	Date	Code	Shares	Price	A/D	Owned after	D/I	Nature of ownership
Common Stock^F1,F2,F3	Nov 2, 2018	C	347,491	—	A	347,491	I	Zac and Cloud Holdings Ltd.
Common Stock^F1,F4,F3	Nov 2, 2018	C	349,862	—	A	697,353	I	Zac and Cloud Holdings Ltd.
Common Stock^F1,F5,F3	Nov 2, 2018	C	187,500	—	A	884,853	I	Zac and Cloud Holdings Ltd.

Security	Conv. / exercise price	Date	Code	Shares	A/D	Exercisable	Expires	Underlying	Underlying shares	D/I
Series A Preferred Stock^F3,F2,F1	—	Nov 2, 2018	C	150,000	D	—	—	Common Stock	347,491	I
Series B-1 Preferred Stock^F3,F4,F1	—	Nov 2, 2018	C	291,551	D	—	—	Common Stock	349,862	I
Series B-2 Preferred Stock^F3,F5,F1	—	Nov 2, 2018	C	156,250	D	—	—	Common Stock	187,500	I

F1Reflects a 1.2-for-1 forward stock split of the Issuer's common stock effected on October 18, 2018.
F2Effective upon the closing of the Issuer's initial public offering of its common stock under the Securities Act of 1933, as amended, each share of Series A preferred stock automatically converted into 2.31660 shares of the Issuer's common stock. The A preferred stock had no expiration date.
F3The shares are held of record by Zac and Cloud Holdings Ltd. ("Cloud"). Zhong Kuang is the sole-shareholder of Cloud and has voting and dispositive power over the shares held by Cloud.
F4Effective upon the closing of the Issuer's initial public offering of its common stock under the Securities Act of 1933, as amended, each share of Series B-1 preferred stock automatically converted into 1.2 shares of the Issuer's common stock. The B-1 preferred stock had no expiration date.
F5Effective upon the closing of the Issuer's initial public offering of its common stock under the Securities Act of 1933, as amended, each share of Series B-2 preferred stock automatically converted into 1.2 shares of the Issuer's common stock. The B-2 preferred stock had no expiration date.