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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1. Name and Address of Reporting Person*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 06/25/2020 |
3. Issuer Name and Ticker or Trading Symbol
Fusion Pharmaceuticals Inc. [ FUSN ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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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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Table I - Non-Derivative Securities Beneficially Owned | |||
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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) |
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) | 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 | ||||
Class A Preferred Shares | (1) | (1) | Common Shares | 401,423 | (1) | I | See footnotes(2)(8) |
Class A Preferred Shares | (1) | (1) | Common Shares | 308,137 | (1) | I | See footnotes(4)(8) |
Class A Preferred Shares | (1) | (1) | Common Shares | 298,898 | (1) | I | See footnotes(5)(8) |
Class A Preferred Shares | (1) | (1) | Common Shares | 447,428 | (1) | I | See footnotes(6)(8) |
Class A Preferred Shares | (1) | (1) | Common Shares | 1,041,456 | (1) | I | See footnotes(7)(8) |
Class B Preferred Shares | (3) | (3) | Common Shares | 161,556 | (3) | I | See footnotes(2)(8) |
Class B Preferred Shares | (3) | (3) | Common Shares | 124,013 | (3) | I | See footnotes(4)(8) |
Class B Preferred Shares | (3) | (3) | Common Shares | 120,294 | (3) | I | See footnotes(5)(8) |
Class B Preferred Shares | (3) | (3) | Common Shares | 180,072 | (3) | I | See footnotes(6)(8) |
Class B Preferred Shares | (3) | (3) | Common Shares | 419,148 | (3) | I | See footnotes(7)(8) |
Warrants to purchase Class B Preferred Shares | 01/10/2020(9) | 01/10/2022(9) | Common Shares | 17,033 | $8.1(9) | I | See footnotes(2)(8) |
Warrants to purchase Class B Preferred Shares | 01/10/2020(9) | 01/10/2022(9) | Common Shares | 13,074 | $8.1(9) | I | See footnotes(4)(8) |
Warrants to purchase Class B Preferred Shares | 01/10/2020(9) | 01/10/2022(9) | Common Shares | 12,682 | $8.1(9) | I | See footnotes(5)(8) |
Warrants to purchase Class B Preferred Shares | 01/10/2020(9) | 01/10/2022(9) | Common Shares | 18,985 | $8.1(9) | I | See footnotes(6)(8) |
Warrants to purchase Class B Preferred Shares | 01/10/2020(9) | 01/10/2022(9) | Common Shares | 44,191 | $8.1(9) | I | See footnotes(7)(8) |
Explanation of Responses: |
1. The Class A Preferred Shares are convertible into Common Shares on a one-for-5.339 basis. Upon the closing of the Issuer's initial public offering, the Class A Preferred Shares will convert into the number of Common Shares shown in column 3. The Class A Preferred Shares have no expiration date. |
2. The shares are held directly by Adams Street 2014 Direct Fund LP ("AS 2014"). |
3. The Class B Preferred Shares are convertible into Common Shares on a one-for-5.339 basis. Upon the closing of the Issuer's initial public offering, the Class B Preferred Shares will convert into the number of Common Shares shown in column 3. The Class B Preferred Shares have no expiration date. |
4. The shares are held directly by Adams Street 2015 Direct Venture/Growth Fund LP ("AS 2015"). |
5. The shares are held directly by Adams Street 2016 Direct Venture/Growth Fund LP ("AS 2016"). |
6. The shares are held directly by Adams Street 2017 Direct Venture/Growth Fund LP ("AS 2017"). |
7. The shares are held directly by Adams Street Venture/Growth Fund VI LP ("ASVG VI"). |
8. Adams Street Partners, LLC as the managing member of the general partner of the general partner of AS 2014, AS 2015, AS 2016, AS 2017 and ASVG VI (collectively the "Funds"), may be deemed to beneficially own the shares held by the Funds. Thomas S. Bremner, Jeffrey T. Diehl, Elisha P. Gould, Robin Murray and Fred Wang, each of whom is a partner of Adams Street Partners, LLC (or a subsidiary thereof), may be deemed to have shared voting and investment power over the shares held by the Funds. Adams Street Partners, LLC and Thomas S. Bremner, Jeffrey T. Diehl, Elisha P. Gould, Robin Murray and Fred Wang disclaim beneficial ownership of the shares held by the Funds except to the extent of their pecuniary interest therein. |
9. Upon the closing of the Issuer's initial public offering, the Warrants to purchase Class B Preferred Shares will become warrants to purchase Common Shares at an exercise price of $8.10 per share. |
Remarks: |
ADAMS STREET PARTNERS, LLC, By: /s/ Sara Robinson Dasse | 06/25/2020 | |
** 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. |