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Maccecchini Maria-Luisa

Filed: 29 Jan 20, 8:07pm
SEC Form 3
FORM 3UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES

Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934
or Section 30(h) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person*
Maccecchini Maria-Luisa

(Last)(First)(Middle)
C/O ANNOVIS BIO, INC.
1055 WESTLAKES DRIVE, SUITE 300

(Street)
BERWYNPA19312

(City)(State)(Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
01/28/2020
3. Issuer Name and Ticker or Trading Symbol
Annovis Bio, Inc. [ ANVS ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
XDirector10% Owner
XOfficer (give title below)Other (specify below)
President and CEO
5. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
XForm filed by One Reporting Person
Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Beneficially Owned
1. Title of Security (Instr. 4)2. Amount of Securities Beneficially Owned (Instr. 4)3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5)4. Nature of Indirect Beneficial Ownership (Instr. 5)
Common Stock, $0.0001 par value206,342D
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 4)2. Date Exercisable and Expiration Date (Month/Day/Year)3. Title and Amount of Securities Underlying Derivative Security (Instr. 4)4. Conversion or Exercise Price of Derivative Security5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5)6. Nature of Indirect Beneficial Ownership (Instr. 5)
Date ExercisableExpiration DateTitleAmount or Number of Shares
Convertible Note(1)(1)Common Stock(1)(1)D
Series A-1 Preferred Stock(2)(2)Common Stock7,937(2)D
Series A Preferred Stock(3)(3)Common Stock762,896(3)D
Stock Option (right to buy)(4)04/06/2028Common Stock85,7140.14D
Stock Option (right to buy)(4)04/07/2026Common Stock50,0000.25D
Explanation of Responses:
1. The Convertible Notes have a maturity date of December 31, 2023. Prior to the maturity date, the Convertible Notes will automatically convert into common stock of Annovis Bio, Inc. ("Annovis") upon an initial public offering ("IPO") of Annovis at a conversion rate equal to the principal amount of the note, plus accrued and unpaid interest, divided by 80% of the public offering price per share of the IPO as set forth on the cover page of the final prospectus for the IPO.
2. Each share of Series A-1 Preferred Stock is convertible into common stock of Annovis and has no expiration date. Upon the closing of the IPO, 11,111 shares of Series A-1 Preferred Stock, along with the aggregate accrued or accumulated and unpaid dividends thereon, will automatically be converted into 7,937 shares of common stock of Annovis.
3. Each share of Series A Preferred Stock is convertible into common stock of Annovis and has no expiration date. Upon the closing of the IPO, 1,068,054 shares of Series A Preferred Stock, along with the aggregate accrued or accumulated and unpaid dividends thereon, will automatically be converted into 762,896 shares of common stock of Annovis.
4. As of the date of this report, all of the shares underlying the options are fully vested and exercisable.
/s/ Maria Maccecchini01/29/2020
** Signature of Reporting PersonDate
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
* If the form is filed by more than one reporting person, see Instruction 5 (b)(v).
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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