Statement of Changes in Beneficial Ownership (4)
November 25 2020 - 5:20PM
Edgar (US Regulatory)
FORM 4
[X]
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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3235-0287
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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
*
Hall Steven Edward |
2. Issuer Name and Ticker or Trading Symbol
Forma Therapeutics Holdings, Inc.
[
FMTX
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__X__ Director _____ 10% Owner _____ Officer (give title below) _____ Other (specify below)
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(Last)
(First)
(Middle)
C/O LILLY VENTURES, 333 N. ALABAMA ST., SUITE 350 |
3. Date of Earliest Transaction
(MM/DD/YYYY)
6/23/2020 |
(Street)
INDIANAPOLIS, IN 46204
(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
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security (Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code (Instr. 8)
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4. Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)
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7. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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Amount
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(A) or (D)
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Price
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Common Stock | 6/23/2020 (1) | | C | | 2106828 (2) | A | (3) | 2404069 | I | See footnote (4) |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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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 |
Series B Preferred Stock | (3) | 6/23/2020 | | C | | | 5833333 | (3) | (3) | Common Stock | 1363723 | $0.00 | 0 | I | See footnote (4) |
Series C Preferred Stock | (3) | 6/23/2020 | | C | | | 3178630 | (3) | (3) | Common Stock | 743105 | $0.00 | 0 | I | See footnote (4) |
Explanation of Responses: |
(1) | This Form 4 is being filed late due to an inadvertent administrative oversight and not any error of the reporting person. |
(2) | Represents the total number of shares of common stock received upon the conversion of the Issuer's preferred stock in connection with the closing of the Issuer's initial public offering on June 23, 2020. |
(3) | All series of preferred stock automatically converted into the Issuer's common stock on a one-for-4.2775 basis upon the closing of the Issuer's initial public offering on June 23, 2020 and had no expiration date. |
(4) | These shares are held directly by Lilly Ventures Fund I, LLC (LVFI). LV Management Group, LLC (LVMG) is the management company for LVFI and has voting and dispositive power over the shares held by LVFI. As such, LVMG may be deemed to indirectly beneficially own the shares held by LVFI. LVMG's voting and dispositive decisions with respect to the shares held by LVFI are made by LVMG's management committee, which includes the Reporting Person. The Reporting Person disclaims beneficial ownership of such shares except to the extent of any pecuniary interest therein. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Hall Steven Edward C/O LILLY VENTURES 333 N. ALABAMA ST., SUITE 350 INDIANAPOLIS, IN 46204 | X |
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Signatures
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/s/ Jeannette Potts, as Attorney-in-Fact | | 11/25/2020 |
**Signature of Reporting Person | Date |
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