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
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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*
280 S. MANGUM STREET, SUITE 350 |
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(Street)
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2. Issuer Name and Ticker or Trading Symbol
Clearside Biomedical, Inc.
[ CLSD ]
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5. 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) |
X |
Other (specify below) |
May be part of a 13(d) Group |
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3. Date of Earliest Transaction
(Month/Day/Year) 01/17/2017
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4. 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 Acquired, Disposed of, or Beneficially Owned |
1. Title of Security (Instr.
3)
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2. Transaction Date
(Month/Day/Year) |
2A. Deemed Execution Date, if any
(Month/Day/Year) |
3. Transaction Code (Instr.
8)
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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)
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7. Nature of Indirect Beneficial Ownership (Instr.
4)
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Code |
V |
Amount |
(A) or (D) |
Price |
Common Stock |
01/17/2017 |
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S |
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9,806 |
D |
$8.92
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2,080,364 |
I |
See Footnote
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Common Stock |
01/18/2017 |
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S |
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12,258 |
D |
$8.64
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2,068,106 |
I |
See Footnote
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Common Stock |
01/19/2017 |
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S |
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7,592 |
D |
$8.22
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2,060,514 |
I |
See Footnote
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Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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1. Title of Derivative Security (Instr.
3)
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2. Conversion or Exercise Price of Derivative Security
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3. Transaction Date
(Month/Day/Year) |
3A. Deemed Execution Date, if any
(Month/Day/Year) |
4. Transaction Code (Instr.
8)
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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)
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8. Price of Derivative Security (Instr.
5)
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9.
Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr.
4)
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10. Ownership Form: Direct (D) or Indirect (I) (Instr.
4)
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11. Nature of Indirect Beneficial Ownership (Instr.
4)
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Code |
V |
(A) |
(D) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
1. Name and Address of Reporting Person*
280 S. MANGUM STREET, SUITE 350 |
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(Street)
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1. Name and Address of Reporting Person*
280 S. MANGUM STREET, SUITE 350 |
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(Street)
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1. Name and Address of Reporting Person*
C/O HATTERAS VENTURES |
280 S. MANGUM STREET, SUITE 350 |
(Street)
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1. Name and Address of Reporting Person*
C/O HATTERAS VENTURES |
280 S. MANGUM STREET, SUITE 350 |
(Street)
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1. Name and Address of Reporting Person*
C/O HATTERAS VENTURES |
280 S. MANGUM STREET, SUITE 350 |
(Street)
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1. Name and Address of Reporting Person*
C/O HATTERAS VENTURES |
280 S. MANGUM STREET, SUITE 350 |
(Street)
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1. Name and Address of Reporting Person*
C/O HATTERAS VENTURES |
280 S. MANGUM STREET, SUITE 350 |
(Street)
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Explanation of Responses: |
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/s/ Thomas A. Allen, attorney-in-fact for Hatteras Venture Advisors IV SBIC, LLC |
01/19/2017 |
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/s/ Thomas A. Allen, attorney-in-fact for Hatteras Venture Advisors IV SBIC, LLC, the general partner of Hatteras Venture Partners IV SBIC, LP |
01/19/2017 |
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/s/ Thomas A. Allen, attorney-in-fact for John C. Crumpler |
01/19/2017 |
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/s/ Thomas A. Allen, attorney-in-fact for Robert A. Ingram |
01/19/2017 |
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/s/ Thomas A. Allen, attorney-in-fact for Kenneth B. Lee |
01/19/2017 |
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/s/ Thomas A. Allen, attorney-in-fact for Douglas Reed |
01/19/2017 |
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/s/ Thomas A. Allen, attorney-in-fact for Clay B. Thorp |
01/19/2017 |
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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
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. |
POWER OF ATTORNEY
Know all by these presents that the undersigned hereby
constitutes and appoints each of Thomas A. Allen and
Andrew J. Gibbons, and each of them acting alone, signing
singly, the undersigned's true and lawful attorney-in-fact
to:
(1) execute for and on behalf of the undersigned, in the
undersigned's capacity as an officer, director, and/or 10%
or more stockholder of Clearside Biomedical , Inc. (the
"Company"), Forms ID, 3, 4 and 5 and Schedules 13D or 13G
(and any amendments thereto) under Section 13(d) and 16(a)
of the Securities Exchange Act of 1934, as amended (the
"1934 Act") in accordance with the 1934 Act, and the rules
promulgated thereunder;
(2) do and perform any and all acts for and on behalf of the
undersigned which may be necessary or desirable to complete
and execute any such Form or Schedule (and any amendments
thereto) and to file timely such Form or Schedule with the
United States Securities and Exchange Commission and any
stock exchange or similar authority; and
(3) 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 present, 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 is the Company assuming, any of the undersigned's
responsibilities to comply with Section 13(d) or 16(a) of the
1934 Act.
This Power of Attorney shall remain in full force and
effect until the undersigned is no longer required to file such
Forms or Schedules 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 each of the foregoing attorneys-in-fact.
IN WITNESS WHEREOF, the undersigned has caused this Power
of Attorney to be executed as of this 18th day of January 2017.
HATTERAS VENTURE ADVISORS IV SBIC, LLC
By: /s/ Clay B. Thorp
Name: Clay B. Thorp
Title: Manager
HATTERAS VENTURE PARTNERS IV SBIC, LP
By: Hatteras Venture Advisors IV SBIC, LLC, its general
partner
By: /s/ Clay B. Thorp
Name: Clay B. Thorp
Title: Manager
/s/ John C. Crumpler
John C. Crumpler
/s/ Robert A. Ingram
Robert A. Ingram
/s/ Kenneth B. Lee
Kenneth B. Lee
/s/ Douglas Reed
Douglas Reed
/s/ Clay B. Thorp
Clay B. Thorp