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*
101 CALIFORNIA STREET; SUITE 4100 |
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(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 05/05/2016
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3. Issuer Name and Ticker or Trading Symbol
Intellia Therapeutics, Inc.
[ NTLA ]
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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 B Preferred Stock |
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Common Stock |
613,688 |
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I |
See Footnote
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1. Name and Address of Reporting Person*
101 CALIFORNIA STREET; SUITE 4100 |
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(Street)
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1. Name and Address of Reporting Person*
101 CALIFORNIA STREET; SUITE 4100 |
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(Street)
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1. Name and Address of Reporting Person*
101 CALIFORNIA STREET; SUITE 4100 |
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(Street)
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Explanation of Responses: |
Remarks: |
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FORESITE CAPITAL MANAGEMENT III, LLC, By: /s/ Dennis D. Ryan, Chief Financial Officer |
05/05/2016 |
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FORESITE CAPITAL FUND III, L.P., By: Foresite Capital Management III, LLC, Its General Partner, By: /s/ Dennis D. Ryan, Chief Financial Officer |
05/05/2016 |
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/s/ James B. Tananbaum |
05/05/2016 |
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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. |
Exhibit 99.1
Pursuant to General Instruction number 5(b)(v) to Form 3, the following
additional reporting persons are covered by this joint filing:
Name: Foresite Capital Fund III, L.P.
James B. Tananbaum
Address: Foresite Capital
101 California Street
Suite 4100
San Francisco, CA 94111
Designated Filer: Foresite Capital Management III, LLC
Issuer and Ticker Symbol: Intellia Therapeutics, Inc. (NTLA)
Date of Event Requiring Statement: May 5, 2016
Each of the following is a Joint Filer with Foresite Capital Management III,
LLC("FCM III") and may be deemed to share indirect beneficial ownership in the
securities set forth on the attached Form 3:
FCM III is the general partner of Foresite Capital Fund III, L.P. ("FCF III").
As such, FCM III possesses sole voting and investment control over the shares
owned by FCF III, and may be deemed to have indirect beneficial ownership of the
securities held by FCF III, however, owns no shares of the Issuer directly. Mr.
Tananbaum is the managing member of FCM III and in his capacity as such, may be
deemed to exercise shared voting, investment and dispositive power over the
shares held by FCF III. Each Reporting Person disclaims beneficial ownership of
the shares held by FCF III except to the extent of his or its proportionate
pecuniary interest therein. The filing of this statement shall not be deemed an
admission that, for purposes of Section 16 of the Securities Exchange Act of
1934, or otherwise, any of the Reporting Persons are the beneficial owners of
all of the equity securities covered by this statement.
Each of the Reporting Persons listed above hereby designates FCM III as its
designated filer of Forms 3, 4 and 5 in accordance with Section 16(a) of the
Securities Exchange Act of 1934 and the rules thereunder.
FORESITE CAPITAL MANAGEMENT III, LLC
By: /s/ Dennis D. Ryan
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Dennis D. Ryan
Chief Financial Officer
FORESITE CAPITAL FUND III, L.P
By: Foresite Capital Management III, LLC
Its General Partner
By: /s/ Dennis D. Ryan
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Dennis D. Ryan
Chief Financial Officer
/s/ James B. Tananbaum
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James B. Tananbaum