Initial Statement of Beneficial Ownership (3)
March 10 2023 - 4:34PM
Edgar (US Regulatory)
FORM 3
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0104
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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
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Amin Rajiv |
2. Date of Event Requiring Statement (MM/DD/YYYY)
3/10/2023
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3. Issuer Name and Ticker or Trading Symbol
IMPEL PHARMACEUTICALS INC [IMPL]
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(Last)
(First)
(Middle)
C/O IMPEL PHARMACEUTICALS INC., 201 ELLIOTT AVE W, STE. 260 |
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director _____ 10% Owner ___X___ Officer (give title below) _____ Other (specify below) VP, Controller & Interim CFO / |
(Street)
SEATTLE, WA 98119
(City)
(State)
(Zip)
| 5. If Amendment, Date Original Filed(MM/DD/YYYY)
| 6. Individual or Joint/Group Filing(Check Applicable Line)
_X_ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person
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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) |
No securities beneficially held | 0 | D | |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security (Instr. 4) | 2. Date Exercisable and Expiration Date (MM/DD/YYYY) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form of Derivative Security: 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 |
Stock Option (right to buy) | (1) | 7/14/2031 (1) | Common Stock | 15500 | $10.02 | D | |
Stock Option (right to buy) | (2) | 7/19/2031 (2) | Common Stock | 10000 | $12.16 | D | |
Stock Option (right to buy) | (3) | 1/25/2032 | Common Stock | 7500 | $9.85 | D | |
Stock Option (right to buy) | (4) | 2/13/2033 | Common Stock | 12000 | $2.29 | D | |
Explanation of Responses: |
(1) | The option vests as to 25% of the total shares on July 13, 2022, then 2.0833% of the total shares vest monthly thereafter, with 100% of the total shares vested and exercisable on July 13, 2025, subject to the reporting person's provision of service to the issuer on each vesting date. |
(2) | The option vests as to 2.0833% of the total shares on August 22, 2021 and then 2.0833% of the total shares vests monthly thereafter, with 100% of the total shares vested and exercisable on July 22, 2025, subject to the reporting person's provision of service to the issuer on each vesting date. |
(3) | The option vests as to 2.0833% of the total shares on February 26, 2022 and then 2.0833% of the total shares vests monthly thereafter, with 100% of the total shares vested and exercisable on January 26, 2026, subject to the reporting person's provision of service to the issuer on each vesting date. |
(4) | The option vests as to 2.0833% of the total shares on March 14, 2023 and then 2.0833% of the total shares vests monthly thereafter, with 100% of the total shares vested and exercisable on February 14, 2027, subject to the reporting person's provision of service to the issuer on each vesting date. |
Remarks: Exhibit 24.1 - Power of Attorney |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Amin Rajiv C/O IMPEL PHARMACEUTICALS INC. 201 ELLIOTT AVE W, STE. 260 SEATTLE, WA 98119 |
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| VP, Controller & Interim CFO |
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Signatures
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/s/ Adrian Adams as attorney-in-fact | | 3/10/2023 |
**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 control number. |
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