SEC Form 4 · accession 0000899243-18-028086

Axonics Modulation Technologies, Inc. · AXNX

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

Reporting owner

Director · Other

Period of report

Nov 2, 2018

Accepted (ET)

Nov 2, 2018 · 7:32 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	289,576	—	A	1,177,576	I	See footnote
Common Stock^F1,F4,F3	Nov 2, 2018	C	925,394	—	A	2,102,970	I	See footnote

Security	Conv. / exercise price	Date	Code	Shares	A/D	Exercisable	Expires	Underlying	Underlying shares	Owned after	D/I
Series A Preferred Stock^F3,F2,F1	—	Nov 2, 2018	C	125,000	D	—	—	Common Stock	289,576	0	I
Series B-1 Preferred Stock^F3,F4,F1	—	Nov 2, 2018	C	771,161	D	—	—	Common Stock	925,394	0	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.
F3These securities are held by The Alfred E. Mann Foundation for Scientific Research. The reporting person disclaims beneficial ownership of these securities, and this report shall not be deemed an admission that the reporting person is the beneficial owner of the securities for purposes of Section 16 or for any other purpose.
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.