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*
C/O ARCH VENTURE PARTNERS |
8725 WEST HIGGINS ROAD, SUITE 290 |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 09/30/2013
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3. Issuer Name and Ticker or Trading Symbol
FATE THERAPEUTICS INC
[ FATE ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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Director |
X |
10% Owner |
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Officer (give title below) |
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Other (specify below) |
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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)
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Form filed by One Reporting Person |
X |
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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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 |
Series A Convertible Preferred Stock |
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Common Stock |
675,493 |
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D
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Series B Convertible Preferred Stock |
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Common Stock |
265,252 |
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D
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Series C Convertible Preferred Stock |
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Common Stock |
570,663 |
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D
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1. Name and Address of Reporting Person*
C/O ARCH VENTURE PARTNERS |
8725 WEST HIGGINS ROAD, SUITE 290 |
(Street)
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1. Name and Address of Reporting Person*
8725 WEST HIGGINS ROAD, SUITE 290 |
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(Street)
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1. Name and Address of Reporting Person*
8725 WEST HIGGINS ROAD, SUITE 290 |
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(Street)
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1. Name and Address of Reporting Person*
8725 WEST HIGGINS ROAD, SUITE 290 |
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(Street)
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1. Name and Address of Reporting Person*
8725 WEST HIGGINS ROAD, SUITE 290 |
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(Street)
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Explanation of Responses: |
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ARCH Venture Fund VI, L.P., By: /s/ Mark McDonnell, as Attorney-in-Fact for Keith Crandell, Managing Director of the general partner of the general partner of ARCH Fund VI |
09/30/2013 |
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ARCH Venture Partners VI, L.P., By: /s/ Mark McDonnell, as Attorney-in-Fact for Keith Crandell, Managing Director of the general partner of the general partner of ARCH Partners VI |
09/30/2013 |
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ARCH Venture Partners VI, LLC, By: /s/ Mark McDonnell, as Attorney-in-Fact for Keith Crandell, Managing Director of the general partner of the general partner of ARCH VI LLC |
09/30/2013 |
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By: /s/ Mark McDonnell, as Attorney-in-Fact for Keith Crandell |
09/30/2013 |
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By: /s/ Mark McDonnell, as Attorney-in-Fact for Clinton Bybee |
09/30/2013 |
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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. |
rrd351626_398233.html
POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS, that each person whose signature appears
below hereby constitutes and appoints Mark McDonnell his true and lawful
attorney-in-fact, with full power of substitution, to sign any and all
instruments, certificates and documents that may be necessary, desirable or
appropriate to be executed on behalf of himself as an individual or in his
capacity as a direct or indirect general partner, director, officer or manager
of any partnership, corporation or limited liability company, pursuant to
section 13 or 16 of the Securities Exchange Act of 1934, as amended (the
"Exchange Act"), and any and all regulations promulgated thereunder, and to file
the same, with all exhibits thereto, and any other documents in connection
therewith, with the Securities and Exchange Commission, and with any other
entity when and if such is mandated by the Exchange Act or by the Financial
Industry Regulatory Authority, granting unto said attorney-in-fact full power
and authority to do and perform each and every act and thing necessary,
desirable or appropriate, fully to all intents and purposes as he might or could
do in person, thereby ratifying and confirming all that said attorney-in-fact,
or his substitutes, may lawfully do or cause to be done by virtue hereof.
IN WITNESS WHEREOF, this Power of Attorney has been signed as of the 10th
day of November, 2010.
ARCH VENTURE FUND VI, L.P.
By: ARCH Venture Partners VI, L.P.
its General Partner
By: ARCH Venture Partners VI, LLC
its General/Partner
By:Keith Crandell
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Managing Director
ARCH VENTURE PARTNERS VI, L.P.
By: ARCH Venture Partners VI, LLC
its General Partner
By:Keith Crandell
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Managing Director
ARCH VENTURE PARTNER VI, LLC
By:Keith Crandell
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Managing Director
/s/ Keith Crandell
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Keith Crandell
/s/ Robert Nelson
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Robert Nelson
/s/ Clinton Bybee
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Clinton Bybee