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
|
OMB APPROVAL |
OMB Number: |
3235-0104 |
Estimated average burden |
hours per response: |
0.5 |
|
|
1. Name and Address of Reporting Person*
C/O APELLIS PHARMACEUTICALS, INC. |
100 FIFTH AVENUE, 3RD FLOOR |
(Street)
|
2. Date of Event Requiring Statement
(Month/Day/Year) 03/30/2021
|
3. Issuer Name and Ticker or Trading Symbol
Apellis Pharmaceuticals, Inc.
[ APLS ]
|
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
|
Director |
|
10% Owner |
X |
Officer (give title below) |
|
Other (specify below) |
Senior Vice President |
|
5. 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 Beneficially Owned |
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 |
8,698 |
D |
|
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
|
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: 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 |
Stock Option (Right to Buy) |
|
01/27/2031 |
Common Stock |
30,000 |
44.9 |
D |
|
Stock Option (Right to Buy) |
|
02/09/2030 |
Common Stock |
18,750 |
44.33 |
D |
|
Stock Option (Right to Buy) |
|
02/04/2028 |
Common Stock |
50,000 |
15.52 |
D |
|
Stock Option (Right to Buy) |
|
02/27/2029 |
Common Stock |
30,000 |
13.85 |
D |
|
Explanation of Responses: |
|
/s/ David Watson, attorney-in-fact for Mark Delong |
04/09/2021 |
|
** 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. |
Know all by these presents, that the undersigned hereby makes,
constitutes and appoints each of David O. Watson and Timothy Sullivan,
signing singly and each acting individually, as the undersigneds true and
lawful attorneyinfact with full power and authority as hereinafter
described to
1 execute for and on behalf of the undersigned, in the undersigneds
capacity as officer 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, as amended,
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 the SEC and
any stock exchange or similar authority, including without limitation the
filing of a Form ID, Update Passphrase, or any other application materials
to enable the undersigned to gain or maintain access to the Electronic Data
Gathering, Analysis and Retrieval system of the SEC
3 seek or obtain, as the undersigneds representative and on the
undersigneds behalf, information regarding transactions in the Companys
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 suchattorneyinfact 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 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 attorneyinfact, 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 undersigneds responsibilities
to comply with Section?16 of the Exchange Act. The undersigned
acknowledges that neither the Company nor the foregoing attorneyinfact
assume i any liability for the undersigneds responsibility to comply
with the requirements 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 undersigneds holdings of and transactions in securities issued
by the Company, unless earlier revoked by the undersigned in a signed
writing delivered to the foregoing attorneyinfact.
IN WITNESS WHEREOF, the undersigned has caused this Power of
Attorney to be executed as of this 31st day of March, 2021. Mark DeLong
Name Mark DeLong
LIMITED POWER OF ATTORNEY
FOR SECTION 16 REPORTING OBLIGATIONS
DC 573852 1301253 v1
ActiveUS 186209981v 1