Initial Statement of Beneficial Ownership (3)
January 10 2020 - 4:22PM
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
*
Alphaeon 1 LLC |
2. Date of Event Requiring Statement (MM/DD/YYYY)
1/8/2020
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3. Issuer Name and Ticker or Trading Symbol
Evolus, Inc. [EOLS]
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(Last)
(First)
(Middle)
4040 MACARTHUR BOULEVARD, SUITE 310 |
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director ___X___ 10% Owner _____ Officer (give title below) _____ Other (specify below)
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(Street)
NEWPORT BEACH, CA 92660
(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) |
Common Stock | 8662346 (1) | 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 |
Explanation of Responses: |
(1) | Pursuant to a Contribution Agreement dated January 8, 2020, by and between the Reporting Person and AEON Biopharma, Inc. (formerly known as Alphaeon Corporation) ("AEON"), on January 8, 2020, the Reporting Person acquired by contribution 8,662,346 shares of the Issuer from AEON (the "Contribution"). The shares of the Issuer contributed to the Reporting Person are deemed "restricted securities" under Rule 144 promulgated under the Securities Act of 1933, as amended. At the time of the Contribution, the Reporting Person was a wholly-owned subsidiary of AEON. Immediately after the Contribution, AEON distributed out all of the membership interests of Reporting Person to its stockholders. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Alphaeon 1 LLC 4040 MACARTHUR BOULEVARD, SUITE 310 NEWPORT BEACH, CA 92660 |
| X |
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Signatures
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/s/ Vik Malik, Manager of ALPHAEON 1 LLC | | 1/8/2020 |
**Signature of Reporting Person | Date |
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