SEC Form 4 · accession 0000899243-18-030617
Axonics Modulation Technologies, Inc. · AXNX
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Erik Amble
Director
Period of report
Dec 6, 2018
Accepted (ET)
Dec 10, 2018 · 9:17 pm EST
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 | Dec 6, 2018 | A | 2,500 | $0.00 | A | 2,500 | D | |
| Common StockF1 | holding | — | — | — | 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 | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Stock Option (Right to Buy)F2 | $14.80 | Dec 6, 2018 | A | 5,000 | A | — | Dec 6, 2028 | Common Stock | 5,000 | 5,000 | D |
Explanation of responses
- F1These 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.
- F2The shares subject to the option will vest in full on April 30, 2019.