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)
06/20/2016
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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)
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Director |
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10% Owner |
| X |
Officer (give title below) |
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Other (specify below) |
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EVP and General Counsel
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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 |
|
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)
|
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)
|
|---|
| 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: |
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| No securities are beneficially owned. |
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/s/ Shalini Sharp, attorney in fact for Karah Parschauer |
06/22/2016 |
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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 present, that the undersigned hereby makes,
constitutes and appoints each of Shalini Sharp and Ryan Murr signing
singly and each acting individually, as the undersigned's 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
undersigned's 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 deliver and file such form(s)
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 undersigned's representative and on the
undersigned's behalf, information regarding transactions in the Company's
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 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 relieving, nor is the Company assuming nor relieving, any
of the undersigned's 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
undersigned's 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 undersigned's 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 20th day of June, 2016.
/s/ Karah Parschauer
Signature
Karah Parschauer
