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*
C/O ULTRAGENYX PHARMACEUTICAL INC. |
60 LEVERONI COURT |
(Street)
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2. Issuer Name and Ticker or Trading Symbol
Ultragenyx Pharmaceutical Inc.
[ RARE ]
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5. 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) |
CFO & Executive Vice President
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3. Date of Earliest Transaction
(Month/Day/Year) 12/23/2016
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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)
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 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 |
12/23/2016 |
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M |
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6,500 |
A |
$0.81
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51,887 |
D |
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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 |
Stock Option (Right to Buy) |
$0.815
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12/23/2016 |
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M |
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6,500 |
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08/01/2022 |
Common Stock |
6,500 |
$0.00
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56,163 |
D |
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Explanation of Responses: |
Remarks: |
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/s/ Ruben Garcia, attorney in fact for Shalini Sharp |
12/23/2016 |
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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
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. |
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, Karah Parschauer, Ruben Garcia
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 Forms 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 DataGathering, 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 at'orney
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
atifying 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 requirements 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 8th day of December, 2016.
/s/ Shalini Sharp
Signature
Shalini Sharp
(Print Name)