Statement of Changes in Beneficial Ownership (4)
August 19 2020 - 04:26PM
Edgar (US Regulatory)
FORM 4
[ ]
Check this box if no longer subject to Section 16. Form 4 or Form 5
obligations may continue. See Instruction 1(b).
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL
OWNERSHIP OF SECURITIES
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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 * JACOBS CINDY |
2. Issuer Name and Ticker or Trading
Symbol ACHIEVE LIFE SCIENCES, INC. [ ACHV ] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)_____
Director _____
10% Owner
__X__ Officer (give title
below) _____ Other
(specify below)
EVP, CMO |
(Last)
(First)
(Middle)
520 PIKE STREET, SUITE 2250 |
3. Date of Earliest Transaction (MM/DD/YYYY)
8/18/2020
|
(Street)
SEATTLE, WA 98101
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line) _X _ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person |
Table I - Non-Derivative Securities Acquired, Disposed of, or
Beneficially Owned
|
1.Title of Security
(Instr. 3) |
2. Trans. Date |
2A. Deemed Execution Date, if any |
3. Trans. Code
(Instr. 8) |
4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5) |
5. Amount of Securities Beneficially Owned Following
Reported Transaction(s)
(Instr. 3 and 4) |
6. Ownership Form: Direct (D) or Indirect (I)
(Instr. 4) |
7. Nature of Indirect Beneficial Ownership (Instr.
4) |
Code |
V |
Amount |
(A) or (D) |
Price |
Common Stock |
8/18/2020 |
|
M |
|
69 (1) |
A |
$0.00 |
209 (2) |
D |
|
Common Stock |
8/18/2020 |
|
F |
|
33 (3) |
D |
$8.95 |
176 |
D |
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Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible
securities)
|
1. Title of Derivate Security
(Instr. 3) |
2. Conversion or Exercise Price of Derivative
Security |
3. Trans. Date |
3A. Deemed Execution Date, if any |
4. Trans. Code
(Instr. 8) |
5. Number of Derivative Securities Acquired (A) or
Disposed of (D)
(Instr. 3, 4 and 5) |
6. Date Exercisable and Expiration Date |
7. Title and Amount of Securities Underlying
Derivative Security
(Instr. 3 and 4) |
8. Price of Derivative Security
(Instr. 5) |
9. Number of derivative Securities Beneficially
Owned Following Reported Transaction(s) (Instr. 4) |
10. Ownership Form of Derivative Security: Direct
(D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr.
4) |
Code |
V |
(A) |
(D) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
Restricted Stock Unit (RSU) |
(4) |
8/18/2020 |
|
M |
|
|
69 (5) |
(6) |
8/1/2021 |
Common Stock |
69 |
$0.00 |
68 |
D |
|
Explanation of
Responses: |
(1) |
Represents shares of common
stock acquired upon settlement of the restricted stock units
("RSUs") listed in Table II. |
(2) |
On July 31, 2020, the Issuer
effected a 1-for-20 split of its common stock (the "Stock Split")
resulting in a decrease of the reporting person's ownership by
2,661 shares of common stock. |
(3) |
Represents shares of common
stock that have been sold by the Issuer to satisfy its income tax
withholding and remittance obligations in connection with the net
settlement of the RSUs and does not represent a sale by the
reporting person. |
(4) |
Each RSU represents a
contingent right to receive one share of the issuer's common stock
at settlement. |
(5) |
This RSU was initially
reported as covering 54,800 shares and was adjusted on May 23, 2018
to reflect a 1-for-10 split, and which number has been adjusted to
reflect the Stock Split. |
(6) |
Pursuant to the terms of the
RSU, 25% of the total shares underlying the RSU vest annually on
the later of (i) each anniversary of August 1, 2017 and (ii) the
first day thereafter during which the issuer's trading window is
open. |
Reporting
Owners
|
Reporting Owner Name / Address |
Relationships
|
Director |
10% Owner |
Officer |
Other |
JACOBS CINDY
520 PIKE STREET
SUITE 2250
SEATTLE, WA 98101 |
|
|
EVP, CMO |
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Signatures
|
Sandra Thomson as attorney-in-fact for Cindy
Jacobs |
|
8/19/2020 |
**Signature of Reporting
Person |
Date |