SEC FORM
4
SEC Form 4
| FORM 4 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934
or Section 30(h) of the Investment Company Act of 1940
|
| OMB APPROVAL |
| OMB Number: |
3235-0287 |
| Estimated average burden |
| hours per response: |
0.5 |
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|
 |
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b). |
1. Name and Address of Reporting Person*
| C/O APELLIS PHARMACEUTICALS, INC |
| 6400 WESTWIND WAY, SUITE A |
(Street)
|
2. Issuer Name and Ticker or Trading Symbol
Apellis Pharmaceuticals, Inc.
[ APLS ]
|
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
| X |
Director |
|
10% Owner |
| X |
Officer (give title below) |
|
Other (specify below) |
| Chief Executive Officer |
|
3. Date of Earliest Transaction
(Month/Day/Year)
06/27/2019
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4. If Amendment, Date of Original Filed
(Month/Day/Year)
|
6. Individual or Joint/Group Filing (Check Applicable Line)
| X |
Form filed by One Reporting Person |
|
Form filed by More than One Reporting Person |
|
| Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned |
|---|
| 1. Title of Security (Instr.
3)
|
2. Transaction Date
(Month/Day/Year) |
2A. Deemed Execution Date, if any
(Month/Day/Year) |
3. Transaction Code (Instr.
8)
|
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)
|
7. Nature of Indirect Beneficial Ownership (Instr.
4)
|
| Code |
V |
Amount |
(A) or (D) |
Price |
| Common Stock |
06/27/2019 |
|
M |
|
275,000 |
A |
$2.14
|
989,288 |
D |
|
| Common Stock |
|
|
|
|
|
|
|
234,411 |
I |
See Footnote
|
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
|
|---|
| 1. Title of Derivative Security (Instr.
3)
|
2. Conversion or Exercise Price of Derivative Security
|
3. Transaction Date
(Month/Day/Year) |
3A. Deemed Execution Date, if any
(Month/Day/Year) |
4. Transaction Code (Instr.
8)
|
5.
Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr.
3, 4 and 5)
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6. Date Exercisable and Expiration Date
(Month/Day/Year) |
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: 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 |
| Stock Option (Right to Buy) |
$2.14
|
06/27/2019 |
|
M |
|
|
275,000 |
|
05/12/2020 |
Common Stock |
275,000 |
$0
|
193,823 |
D |
|
| Explanation of Responses: |
|
|
|
/s/ David Watson, attorney-in-fact for Cedric Francois |
07/01/2019 |
|
** 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
4
(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
attorney-in-fact 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
16(a) 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 attorney-in-fact
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 attorney-in-fact,
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
attorney-in-fact 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 attorney-in-fact may approve
in such attorney-in-fact's discretion. The
undersigned hereby grants to each such
attorney-in-fact 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
resent, with full power of substitution or revocation,
hereby ratifying and confirming all that such
attorney-in-fact, or such attorney-in-fact'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
attorneys-in-fact, 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 attorneys-in-fact 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 16(b) 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
attorneys-in-fact. IN WITNESS WHEREOF, the undersigned
has caused this Power of Attorney to be executed as of
this 6th day of November, 2017.
Signature
Cedric Francois Print Name
