SEC Form 3
FORM 3 | UNITED 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*
(Street)
| 2. Date of Event Requiring Statement (Month/Day/Year) 06/25/2020 | 3. Issuer Name and Ticker or Trading Symbol Akouos, Inc. [ AKUS ] | |||||||||||||
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
| 5. If Amendment, Date of Original Filed (Month/Day/Year) | ||||||||||||||
6. Individual or Joint/Group Filing (Check Applicable Line)
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Table I - Non-Derivative Securities Beneficially Owned | |||
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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) |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
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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 Security | 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 6. Nature of Indirect Beneficial Ownership (Instr. 5) | ||
Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Series Seed Preferred Stock | (1) | (1) | Common Stock | 513,757 | (1) | I | See Footnotes(2)(3) |
Series A Preferred Stock | (4) | (4) | Common Stock | 1,997,946 | (4) | I | See Footnotes(3)(5) |
Series B Preferred Stock | (6) | (6) | Common Stock | 1,799,964 | (6) | I | See Footnotes(3)(7) |
Explanation of Responses: |
1. The Series Seed Preferred Stock is convertible into Common Stock on a 21.073-for-1 basis into the number of shares of Common Stock as shown in Column 3 at the holder's election or upon closing of the initial public offering of the Issuer's common stock without payment of further consideration. The shares have no expiration date. |
2. Consists of 513,757 shares held by 5AM Ventures V, L.P. ("Ventures V"). |
3. 5AM Partners V, LLC is the general partner of Ventures V and may be deemed to have sole investment and voting power over the shares held by Ventures V. The Reporting Person is a Managing Member of 5AM Partners V, LLC, and may be deemed to have shared voting and dispositive power over the shares held by Ventures V. 5AM Opportunities I (GP), LLC is the general partner of 5AM Opportunities I, L.P. ("Opportunities I") and may be deemed to have sole investment and voting power over the shares held by Opportunities I. The Reporting Person is a Managing Member of 5AM Opportunities I (GP), LLC, and may be deemed to have shared voting and dispositive power over the shares held by Opportunities I. Therefore, the Reporting Person may be deemed to beneficially own the shares held by Ventures V and Opportunities I. The Reporting Person disclaims beneficial ownership over the shares held by Ventures V and Opportunities I except to the extent of his pecuniary interest therein. |
4. The Series A Preferred Stock is convertible into Common Stock on a 21.073-for-1 basis into the number of shares of Common Stock as shown in Column 3 at the holder's election or upon closing of the initial public offering of the Issuer's common stock without payment of further consideration. The shares have no expiration date. |
5. Consists of 1,997,946 shares held by Ventures V. |
6. The Series B Preferred Stock is convertible into Common Stock on a 21.073-for-1 basis into the number of shares of Common Stock as shown in Column 3 at the holder's election or upon closing of the initial public offering of the Issuer's common stock without payment of further consideration. The shares have no expiration date. |
7. Consists of 999,980 shares held by Ventures V and 799,984 shares held by Opportunities I. |
Remarks: |
Exhibit Index: 24.1 Power of Attorney |
/s/ Karoline K. Shair, as attorney-in-fact for Kush Parmar | 06/25/2020 | |
** Signature of Reporting Person | Date | |
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). | ||
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. | ||
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. |