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*
109 N. POST OAK LANE, SUITE 600 |
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(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 06/20/2018
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3. Issuer Name and Ticker or Trading Symbol
XERIS PHARMACEUTICALS INC
[ XERS ]
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4. 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) |
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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)
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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 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 |
Series A Preferred Stock
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|
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Common Stock |
930,383 |
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D |
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Series B Preferred Stock
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|
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Common Stock |
581,992 |
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D |
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Series B Preferred Stock
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Common Stock |
447,686 |
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D |
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Stock Option (right to buy) |
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02/25/2025 |
Common Stock |
11,228 |
1.98 |
D |
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1. Name and Address of Reporting Person*
109 N. POST OAK LANE, SUITE 600 |
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(Street)
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1. Name and Address of Reporting Person*
109 N. POST OAK LANE, SUITE 600 |
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(Street)
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1. Name and Address of Reporting Person*
109 N. POST OAK LANE, SUITE 600 |
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(Street)
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Explanation of Responses: |
Remarks: |
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Palmetto Partners, Ltd., by /s/ Ben D. Smolij, attorney in fact |
06/20/2018 |
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Palmetto Partners, Ltd., by /s/ Ben D. Smolij, attorney in fact |
06/20/2018 |
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Palmetto Partners, Ltd., by /s/ Ben D. Smolij, attorney in fact |
06/20/2018 |
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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. |
POWER OF ATTORNEY
Know all by these presents,that
the undersigned hereby constitutes
and appoints each of Wade Turner,
Michael J. Blankenship, and Ben D.
Smolij, or each of them acting
individually, the undersigned's
true and lawful attorney-in-fact
to:
(1) execute for and on behalf of
the undersigned a Form ID
application to be filed with the
Securities and Exchange Commission
to obtain EDGAR codes for the
undersigned;
(2) execute for and on behalf of
the undersigned Forms 3, 4, and 5
with respect to the securities
of Xeris Pharmaceuticals, Inc.
(the "Company") in accordance with
Section 16(a) of the Securities and
Exchange Act of 1934 and the rules
thereunder;
(3) 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 ID application or Form 3, 4,
or 5, complete and execute any
amendment or amendments thereto,
and timely file such forms with
the United States Securities and
Exchange Commission and any stock
exchange or similar authority; 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-
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 16 of the Securities
Exchange Act of 1934, as amended.
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 this 20th day of June
2018.
PALMETTO PARTNERS, LTD.
By: Palmetto Partners GP LLC, its
General Partner
By: Greg S. Watson,
Senior Vice President
POWER OF ATTORNEY
Know all by these presents,that
the undersigned hereby constitutes
and appoints each of Wade Turner,
Michael J. Blankenship, and Ben D.
Smolij, or each of them acting
individually, the undersigned's
true and lawful attorney-in-fact
to:
(1) execute for and on behalf of
the undersigned a Form ID
application to be filed with the
Securities and Exchange Commission
to obtain EDGAR codes for the
undersigned;
(2) execute for and on behalf of
the undersigned Forms 3, 4, and 5
with respect to the securities
of Xeris Pharmaceuticals, Inc.
(the "Company") in accordance with
Section 16(a) of the Securities and
Exchange Act of 1934 and the rules
thereunder;
(3) 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 ID application or Form 3, 4,
or 5, complete and execute any
amendment or amendments thereto,
and timely file such forms with
the United States Securities and
Exchange Commission and any stock
exchange or similar authority; 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-
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 16 of the Securities
Exchange Act of 1934, as amended.
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 this 20th day of June
2018.
PALMETTO PARTNERS 2014, LP
By: Palmetto Partners GP LLC, its
General Partner
By: Greg S. Watson,
Senior Vice President
POWER OF ATTORNEY
Know all by these presents,that
the undersigned hereby constitutes
and appoints each of Wade Turner,
Michael J. Blankenship, and Ben D.
Smolij, or each of them acting
individually, the undersigned's
true and lawful attorney-in-fact
to:
(1) execute for and on behalf of
the undersigned a Form ID
application to be filed with the
Securities and Exchange Commission
to obtain EDGAR codes for the
undersigned;
(2) execute for and on behalf of
the undersigned Forms 3, 4, and 5
with respect to the securities
of Xeris Pharmaceuticals, Inc.
(the "Company") in accordance with
Section 16(a) of the Securities and
Exchange Act of 1934 and the rules
thereunder;
(3) 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 ID application or Form 3, 4,
or 5, complete and execute any
amendment or amendments thereto,
and timely file such forms with
the United States Securities and
Exchange Commission and any stock
exchange or similar authority; 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-
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 16 of the Securities
Exchange Act of 1934, as amended.
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 this 20th day of June
2018.
PALMETTO PARTNERS 2015, LP
By: Palmetto Partners GP LLC, its
General Partner
By: Greg S. Watson,
Senior Vice President