SEC Form 4 · accession 0000899243-18-028091
Axonics Modulation Technologies, Inc. · AXNX
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Period of report
Nov 2, 2018
Accepted (ET)
Nov 2, 2018 · 7:34 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 StockF1,F2,F3 | Nov 2, 2018 | C | 2,266,666 | — | A | 2,266,666 | I | By Cooperatieve Gilde Healthcare IV U.A. |
| Common StockF1,F3 | Nov 2, 2018 | P | 866,666 | $15.00 | A | 3,133,332 | I | By Cooperatieve Gilde Healthcare IV U.A. |
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Series C Preferred StockF3,F2,F1 | — | Nov 2, 2018 | C | 1,888,888 | D | — | — | Common Stock | 2,266,666 | 0 | I |
Explanation of responses
- 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 C preferred stock automatically converted into 1.2 shares of the Issuer's common stock. The Series C preferred stock had no expiration date.
- F3The shares are held directly by Cooperatieve Gilde Healthcare IV U.A. ("Gilde"). Geoff Pardo ("Pardo"), who is a member of the Issuer's board of directors, is a partner of Gilde. Gilde is managed IV Management B.V. ("Management"). Management is owned by Gilde Healthcare Holding B.V. ("Holding"). Each of Pardo, Management and Holding may be deemed to have voting, investment and dispositive power with respect to these securities. Each of Pardo, Management and Holding disclaims beneficial ownership of these securities and this report shall not be deemed an admission that any of them is the beneficial owner of such securities for purposes of Section 16 or for any other purpose, except to the extent of their respective pecuniary interests therein.