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 ULTRAGENYX PHARMACEUTICAL INC. |
60 LEVERONI COURT |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 03/17/2016
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3. Issuer Name and Ticker or Trading Symbol
Ultragenyx Pharmaceutical Inc.
[ RARE ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X |
Director |
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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)
X |
Form filed by One Reporting Person |
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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 |
Explanation of Responses: |
Remarks: |
No securities are beneficially owned. |
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/s/ Lars Ekman, M.D., Ph.D. |
03/21/2016 |
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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. |
LIMITED POWER OF ATTORNEY FOR SECTION 16 REPORTING OBLIGATIONS
Know all by these presents, that the undersigned hereby makes, constitutes
and appoints each of Shalini Sharp and Ryan Murr signing singly and each
acting individually, as the undersigneds true and lawful attorney in fact
with full power and authority as hereinafter described to:
(1) execute for and on behalf of the undersigned, in the undersigneds
capacity as an officer and/or director and/or stockholder of Ultragenyx
Pharmaceutical Inc. (the Company), Forms 3, 4, and 5 (including any
amendments
thereto) in accordance with Section 16(a) of the Securities Exchange
Act of 1934 and the rules thereunder (the Exchange Act);
(2) do and perform any and all acts for and on behalf of the
undersigned which may be necessary or desirable to prepare, complete
and execute any such Form 3, 4,or 5, prepare, complete and execute any
amendment or amendments thereto, and timely deliver and file such form
with the United States Securities and Exchange Commission (the SEC)
and any stock exchange or similar authority, including without limitation
the filing of a Form ID or any other application materials to enable
the undersigned to gain or maintain access to the Electronic Data
Gathering, Analysis and Retrieval system of the SEC;
(3) seek or obtain, as the undersigneds representative and on the
undersigneds behalf, information regarding transactions in the Companys
securities from any third
party, including brokers, employee benefit plan administrators and trustees,
and the undersigned hereby authorizes any such person to release any such
information to such attorney in fact and approves and ratifies any such
release of information; and (4) 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 facts 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 facts 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 relieving, nor is the Company assuming
nor relieving,any of the undersigneds responsibilities to comply with
Section 16 of the Exchange Act. The undersigned acknowledges that
neither the Company nor the foregoing attorneys in fact assume
(i) any liability for the undersigneds responsibility to comply with the
requirement of the Exchange Act, (ii) any liability of the undersigned
for any failure to comply with such requirements, or (iii) any obligation
or liability of the undersigned for profit disgorgement under
Section 16(b) of the Exchange Act. This Power of Attorney shall
remain in full force and effect until the undersigned is no
longer required to file Forms 3, 4, and 5 with respect to the
undersigneds holdings of and transactions in securities issued
by the Company, unless earlier revoked by the undersigned in a signed
writing delivered to the foregoing attorneys in fact.
IN WITNESS WHEREOF, the undersigned has caused this Power
of Attorney to be executed as of this 21st day of March, 2016.
/s/ Lars Ekman, M.D., Ph.D.
Signature
Lars Ekman, M.D., Ph.D.
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