UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | SEC 1473 (7-02) | ||
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. |
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 of Derivative Security: Direct (D) or Indirect (I) (Instr. 5) |
6. Nature of Indirect Beneficial Ownership (Instr. 5) |
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Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Series A Preferred Stock | Â (3) | Â (3) | Common Stock | 401,927 | $ (3) | D (1) | Â |
Series A Preferred Stock | Â (3) | Â (3) | Common Stock | 555,956 | $ (3) | D (2) | Â |
Series B Preferred Stock | Â (3) | Â (3) | Common Stock | 44,364 | $ (3) | D (1) | Â |
Series B Preferred Stock | Â (3) | Â (3) | Common Stock | 61,366 | $ (3) | D (2) | Â |
Convertible Promissory Notes | Â (4) | Â (4) | Common Stock | 805,856.5 (4) | $ (4) | D (1) | Â |
Convertible Promissory Notes | Â (4) | Â (4) | Common Stock | 114,665.38 (4) | $ (4) | D (2) | Â |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
NGN BIOMED OPPORTUNITY I GMBH & CO. BETEILIGUNGS KG C/O HORIZON PHARMA, INC. 1033 SKOKIE BLVD., SUITE 355 NORTHBROOK, IL 60062 |
 |  X |  |  |
NGN BioMed Opportunity I L P C/O HORIZON PHARMA, INC. 1033 SKOKIE BLVE., SUITE 355 NORTHBROOK, IL 60062 |
 |  X |  |  |
/s/ See Exhibit 99.1 | 07/28/2011 | |
**Signature of Reporting Person | Date |
* | 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). |
(1) | Securities held in the name of NGN Biomed Opportunity I GmbH & Co. Beteiligungs KG. |
(2) | Securities held in the name of NGN Biomed Opportunity I, L.P. |
(3) | The shares of Series A Preferred Stock and Series B Preferred Stock have no expiration date and are convertible at any time at the election of the holder. Every 2.374 shares of preferred stock will automatically convert into one share of common stock upon the closing of the Issuer's initial public offering. |
(4) | Principal and accrued interest will convert upon the Issuer's initial public offering into shares of Common Stock at a conversion price equal to the lesser of (i) the public offering price of the Common Stock sold in the Issuer's initial public offering, or (ii) $18.92. Amounts shown are reported in US dollars and include interest accrued through the date hereof; additional interest will accrue prior to conversion. |