SEC Form 4 · accession 0000899243-18-028099

Axonics Modulation Technologies, Inc. · AXNX

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

Reporting owner

Erik Amble

Director · Other

Period of report

Nov 2, 2018

Accepted (ET)

Nov 2, 2018 · 7:40 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	451,738	—	A	451,738	I	By NeoMed Innovation V, L.P.
Common Stock^F1,F4,F3	Nov 2, 2018	C	455,610	—	A	907,348	I	By NeoMed Innovation V, L.P.
Common Stock^F1,F5,F3	Nov 2, 2018	C	243,750	—	A	1,151,098	I	By NeoMed Innovation V, L.P.
Common Stock^F1,F6,F3	Nov 2, 2018	C	369,786	—	A	1,520,884	I	By NeoMed Innovation V, L.P.

Table II — derivative securities

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	195,000	D	—	—	Common Stock	451,738	I
Series B-1 Preferred Stock^F3,F4,F1	—	Nov 2, 2018	C	379,675	D	—	—	Common Stock	455,610	I
Series B-2 Preferred Stock^F3,F5,F1	—	Nov 2, 2018	C	203,125	D	—	—	Common Stock	243,750	I
Series C Preferred Stock^F3,F6,F1	—	Nov 2, 2018	C	308,155	D	—	—	Common Stock	369,786	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 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 NeoMed Innovation V, L.P. ("NeoMed"). NeoMed Innovation V Limited is the general partner of NeoMed and has voting and dispositive power over the shares held by NeoMed. Erik Amble, Ph.D., who is a member of the Issuer's board of directors, is a director of NeoMed Innovation V Limited, and may be deemed to have voting and dispositive power over the shares held by NeoMed. Mr. Amble disclaims beneficial ownership of these securities and this report shall not be deemed an admission that Mr. Amble is the beneficial owner of such securities for purposes of Section 16 or for any other purpose, except to the extent of his respective pecuniary interest therein.
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.
F6Effective 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 C preferred stock had no expiration date.