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*
27 DRYDOCK AVENUE, 8TH FLOOR |
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(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 06/11/2019
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3. Issuer Name and Ticker or Trading Symbol
SYNLOGIC, INC.
[ SYBX ]
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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 |
6,340,771 |
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 |
Class A Warrants to Purchase Common Stock |
06/11/2019
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06/11/2044 |
Common Stock |
2,548,117
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0.01 |
D |
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Explanation of Responses: |
Remarks: |
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/s/ Reshma Shetty, Attorney-in-Fact |
06/19/2019 |
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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. |
EXHIBIT 24 TO FORM 3
POWER OF ATTORNEY
The undersigned hereby makes, constitutes and appoints each of Reshma Shetty, Austin Che and Karen Tepichen (each, an “Attorney”), signing singly, with full power of substitution, a true and lawful attorney-in-fact for the undersigned, in the undersigned’s name, place and stead and on
the undersigned’s behalf, to complete, execute and file with the United States Securities and Exchange Commission, one or more initial statements of beneficial ownership of securities, statements of changes in beneficial ownership of securities,
annual statements of beneficial ownership of securities and/or information statements pursuant to Sections 16(a), 13(d) and/or 13(g) of the Securities Exchange Act of 1934 and the rules and regulations thereunder, and any other amendments, forms,
certificates, documents or instruments that the Attorney deems necessary or appropriate in order to comply with the requirements of said Sections 16(a), 13(d) and/or 13(g) and said rules and regulations.
The undersigned hereby acknowledges that the Attorneys, in serving in such capacity at the undersigned’s request, are not
assuming any of the undersigned’s responsibilities to comply with Sections 16(a), 13(d) and/or 13(g) of the Securities Exchange Act of 1934 and the rules and regulations thereunder.
This Power of Attorney shall remain in effect unless a written revocation thereof is delivered to the Attorneys.
Dated: June 19, 2019.
GINKGO BIOWORKS,
INC.
By: /s/ Jason Kelly
Name: Jason Kelly
Title: Chief Executive Officer