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 ALTIMMUNE, INC. |
19 FIRSTFIELD ROAD, SUITE 200 |
(Street)
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2. Issuer Name and Ticker or Trading Symbol
Altimmune, Inc.
[ ALT ]
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5. 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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3. Date of Earliest Transaction
(Month/Day/Year) 10/13/2017
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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 |
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 Options (option to buy) |
$2.5
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10/13/2017 |
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A |
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20,000 |
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04/30/2018 |
10/13/2027 |
Common Stock, par value $0.0001 |
20,000 |
$0
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20,000 |
D |
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Explanation of Responses: |
Remarks: |
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/s/ Ori Solomon, Attorney in fact for Mitchel Sayare |
10/17/2017 |
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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 PURPOSES
Know all by these presents, that the undersigned hereby
makes, constitutes and appoints Elizabeth Czerepak and Ori
Solomon, each acting individually, as the undersigned's true and
lawful attorneys-in-fact, with full power and authority as
hereinafter described on behalf of and in the name, place and
stead of the undersigned to:
(1) execute for, and on behalf of, the undersigned, in
the undersigned 's capacity as an officer, director and/or 10%
beneficial owner of Altimmune, Inc. (the "Company"), Forms 3,
4, and 5 in accordance with Section 16(a) of the Securities
Exchange Act of 1934 and the rules and regulations promulgated
thereunder (the "Exchange Act");
(2) seek or obtain, as the undersigned's representative
and on the undersigned's behalf, information on 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 any attorney-in-fact and further approves and
ratifies any such release of information;
(3) do and perform any and all acts for and on behalf of
the undersigned that may be necessary or desirable to prepare,
complete and execute any such Form 3, 4 or 5, and any amendments
thereto, or other required report and timely file such Forms or
reports with the United States Securities and Exchange Commission
(the "Commission"), the NASDAQ and any stock exchange or
similar authority as considered necessary or advisable under Section
l 6(a) of the Exchange Act (including, without limitation, executing
and delivering a Form ID to the Commission to obtain EDGAR filing
codes); 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
Limited 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 sole discretion.
The undersigned hereby gives and 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 hereby acknowledges that (a) the foregoing attorneys-
in-fact are serving in such capacity at the request of the undersigned;
(b) this Limited Power of Attorney authorizes, but does not require,
each such attorney-in-fact to act in his or her discretion on information
provided to such attorney-in-fact without independent verification of
such information; (c) any documents prepared and/or executed by any
attorney-in-fact on behalf of the undersigned pursuant to this Limited
Power of Attorney shall be in such forma and shall contain such
information and disclosure as such attorney-in-fact, in his or her sole
discretion, deems necessary or advisable; (d) neither the Company nor
any attorney-in-fact assumes (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; and (e)
this Limited Power of Attorney does not relieve the undersigned from
responsibility for compliance with the undersigned's obligations under
the Exchange Act, including, without limitation, the reporting
requirements under Section 16 of the Exchange Act.
This Limited 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 revoke as to any attorney-in-fact
by the undersigned in a signed writing delivered to such attorney-in-fact.
IN WITNESS WHEREOF, the undersigned has caused this Power of
Attorney to be executed as of this 6th day of June, 2017.
/s/ Mitchel B. Sayare, Ph.D.
Mitchel B. Sayare, Ph.D.
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