SEC FORM
3
SEC Form 3
| FORM 3 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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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| OMB APPROVAL |
| OMB Number: |
3235-0104 |
| Estimated average burden |
| hours per response: |
0.5 |
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1. Name and Address of Reporting Person*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
01/03/2023
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3. Issuer Name and Ticker or Trading Symbol
Apellis Pharmaceuticals, Inc.
[ APLS ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
|
Director |
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10% Owner |
| X |
Officer (give title below) |
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Other (specify below) |
| Chief Medical Officer |
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5. If Amendment, Date of Original Filed
(Month/Day/Year)
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6. Individual or Joint/Group Filing (Check Applicable Line)
| X |
Form filed by One Reporting Person |
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Form filed by More than One Reporting Person |
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| Table I - Non-Derivative Securities Beneficially Owned |
|---|
| 1. Title of Security (Instr.
4)
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2.
Amount of Securities Beneficially Owned (Instr.
4)
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3. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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4. Nature of Indirect Beneficial Ownership (Instr.
5)
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| Common Stock |
133.37 |
D |
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Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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|---|
| 1. Title of Derivative Security (Instr.
4)
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2. Date Exercisable and Expiration Date
(Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr.
4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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6. Nature of Indirect Beneficial Ownership (Instr.
5)
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| Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
| Explanation of Responses: |
|
/s/ David Watson, attorney-in-fact for Caroline Baumal |
01/05/2023 |
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** 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 Number. |
LIMITED POWER OF ATTORNEY FOR SECTION 16 REPORTING OBLIGATIONS
Know all by these presents, that the undersigned hereby makes, constitutes
and appoints each of David Watson and Timothy Sullivan, signing singly
and each acting individually, as the undersigned?s true and lawful
attorneyinfact with full power and authority as hereinafter described to
1 execute for and on behalf of the undersigned, in the undersigned?s
capacity as an officer and/or director of Apellis Pharmaceuticals, Inc.
the Company, Forms 3, 4, and 5 including any amendments thereto in
accordance with Section 16a of the Securities Exchange Act of 1934 and
the rules thereunder the Exchange Act
2 do and perform any and all acts for and on behalf of the undersigned
which may be necessary or desirable to prepare, complete and execute any
such Form 3, 4, or 5, prepare, complete and execute any amendment or
amendments thereto, and timely deliver and file such form with the United
States Securities and Exchange Commission and any stock exchange or
similar authority
3 seek or obtain, as the undersigned?s representative and on the
undersigned?s behalf, information regarding transactions in the Company?s
securities from any third party, including brokers, employee benefit plan
administrators and trustees, and the undersigned hereby authorizes any such
person to release any such information to such attorneyinfact and approves
and ratifies any such release of information and
4 take any other action of any type whatsoever in connection with the
foregoing which, in the opinion of such attorneyinfact, may be of benefit
to, in the best interest of, or legally required by, the undersigned, it
being understood that the documents executed by such attorneyinfact on
behalf of the undersigned pursuant to this Power of Attorney shall be in
such form and shall contain such terms and conditions as such
attorneyinfact may approve in such attorneyinfact?s discretion.
The undersigned hereby grants to each such attorneyinfact full power
and authority to do and perform any and every act and thing whatsoever
requisite, necessary, or proper to be done in the exercise of any of the
rights and powers herein granted, as fully to all intents and purposes
as the undersigned might or could do if personally present, with full power
of substitution or revocation, hereby ratifying and confirming all that
such attorneyinfact, or such attorneyinfact?s substitute or substitutes,
shall lawfully do or cause to be done by virtue of this power of attorney
and the rights and powers herein granted. The undersigned acknowledges
that the foregoing attorneysinfact, in serving in such capacity at the
request of the undersigned, are not assuming nor relieving, nor is the
Company assuming nor relieving, any of the undersigned?s responsibilities
to comply with Section 16 of the Exchange Act. The undersigned acknowledges
that neither the Company nor the foregoing attorneysinfact assume i
any liability for the undersigned?s responsibility to comply with the
requirement of the Exchange Act, ii any liability of the undersigned for
any failure to comply with such requirements, or iii any obligation or
liability of the undersigned for profit disgorgement under Section 16b
of the Exchange Act.
This Power of Attorney shall remain in full force and effect until the
undersigned is no longer required to file Forms 3, 4, and 5 with respect
to the undersigned?s holdings of and transactions in securities issued by
the Company, unless earlier revoked by the undersigned in a signed writing
delivered to the foregoing attorneysinfact.
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to
be executed as of this 3 day of January, 2023.
Signature
Caroline Baumal Print Name
ActiveUS 179092563v.2
