SEC Form 4 · accession 0000899243-18-028105
Axonics Modulation Technologies, Inc. · AXNX
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Raymond W Cohen
Officer — Chief Executive Officer · Director
Period of report
Nov 2, 2018
Accepted (ET)
Nov 2, 2018 · 7:44 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 | 8,760 | — | A | 688,651 | I | See footnote |
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Series B-1 Preferred StockF2,F1 | — | Nov 2, 2018 | C | 7,300 | D | — | — | Common Stock | 8,760 | 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 B-1 preferred stock automatically converted into 1.2 shares of the Issuer's common stock. The Series B-1 preferred stock had no expiration date.
- F38,760 shares are held of record by Cielo Trust Established March 30, 2018 and 679,891 shares are held of record by the reporting person.