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*
| 1701 N. CONGRESS AVENUE, SUITE 6-127 |
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(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
10/05/2015
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3. Issuer Name and Ticker or Trading Symbol
Mirna Therapeutics, Inc.
[ MIRN ]
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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)
| 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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| Common Stock |
2,395,010 |
D |
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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: |
|
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/s/ Wayne R. Roberts, Chief Executive Officer, on behalf of Cancer Prevention and Research Institute of Texas |
10/08/2015 |
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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. |
CONFIRMING STATEMENT
This Statement confirms that the undersigned, Cancer Prevention and
Research Institute of Texas, has authorized and designated each of Wayne R.
Roberts and Heidi M. McConnell to execute and file on the undersigned's behalf
all Forms 3, 4, and 5 (including any amendments thereto) that the undersigned
may be required to file with the U.S. Securities and Exchange Commission as a
result of the undersigned's ownership of or transactions in securities of Mirna
Therapeutics, Inc. The authority of Wayne R. Roberts and Heidi M. McConnell
under this Statement shall continue until the undersigned is no longer required
to file Forms 3, 4, and 5 with regard to the undersigned's ownership of or
transactions in securities of Mirna Therapeutics, Inc., unless earlier revoked
in writing. The undersigned acknowledges that neither Wayne R. Roberts nor Heidi
M. McConnell is assuming any of the undersigned's responsibilities to comply
with Section 16 of the Securities Exchange Act of 1934.
Date: October 7, 2015 Cancer Prevention and Research Institute
of Texas
By: /s/ Wayne R. Roberts
-----------------------------------
Name: Wayne R. Roberts
Title: Chief Executive Officer
