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 (1) | Â (1) | Common Stock | 98,595 | $ (1) | D | Â |
Stock Option (Right to Buy) | Â (2) | 11/16/2021 | Common Stock | 109,734 | $ 0.3135 | D | Â |
Stock Option (Right to Buy) | Â (3) | 10/31/2023 | Common Stock | 39,878 | $ 6.8646 | D | Â |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Kassberg Thomas Richard C/O ULTRAGENYX PHARMACEUTICAL INC. 60 LEVERONI COURT NOVATO, CA 94949 |
 |  |  See Remarks |  |
By: /s/ Thomas Kassberg | 01/30/2014 | |
**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) | Each share of Series A Convertible Preferred Stock automatically converts into Common Stock on a 1-for-3.1345 basis immediately prior to the closing of the Issuer's initial public offering of Common Stock and has no expiration date. The number of underlying shares of common stock reported in Column 3 does not reflect this 1-for-3.1345 reverse stock split, pursuant to which each share of Series A Convertible Preferred Stock will become convertible into 0.3190 of a share of common stock. |
(2) | 1/4th of the option shall vest one year from November 15, 2011 and then the remaining shares vest monthly until November 15, 2015, provided the Reporting Person has not terminated services with the Issuer. |
(3) | 1/4th of the option shall vest one year from November 1, 2013 and then the remaining shares vest monthly until November 1, 2017, provided the Reporting Person has not terminated services with the Issuer. |
 Remarks: Chief Business Officer and Senior Vice President Exhibit List Exhibit 24 - Limited Power of Attorney |