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 DOMAIN ASSOCIATES, LLC |
ONE PALMER SQUARE |
(Street)
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2. Issuer Name and Ticker or Trading Symbol
Evoke Pharma Inc
[ EVOK ]
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5. 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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3. Date of Earliest Transaction
(Month/Day/Year) 04/06/2016
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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)
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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 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 |
04/06/2016 |
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S |
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8,669 |
D |
$5.22
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1,043,659 |
D
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Common Stock |
04/07/2016 |
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S |
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27,781 |
D |
$5.26
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1,015,878 |
D
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Common Stock |
04/08/2016 |
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S |
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14,554 |
D |
$5.35
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1,001,324 |
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 |
1. Name and Address of Reporting Person*
C/O DOMAIN ASSOCIATES, LLC |
ONE PALMER SQUARE |
(Street)
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1. Name and Address of Reporting Person*
C/O DOMAIN ASSOCIATES, LLC |
ONE PALMER SQUARE |
(Street)
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1. Name and Address of Reporting Person*
C/O DOMAIN ASSOCIATES, LLC |
ONE PALMER SQUARE |
(Street)
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1. Name and Address of Reporting Person*
C/O DOMAIN ASSOCIATES, LLC |
ONE PALMER SQUARE |
(Street)
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1. Name and Address of Reporting Person*
C/O DOMAIN ASSOCIATES, LLC |
ONE PALMER SQUARE |
(Street)
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1. Name and Address of Reporting Person*
C/O DOMAIN ASSOCIATES, LLC |
ONE PALMER SQUARE |
(Street)
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Explanation of Responses: |
Remarks: |
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/s/ Lisa A. Kraeutler, as Attorney-in-Fact for Domain Partners VII, L.P., James C. Blair, Brian H. Dovey, Jesse I. Treu, Nicole Vitullo & Brian K. Halak |
04/08/2016 |
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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. |
Unassociated Document
POWER OF ATTORNEY
THE UNDERSIGNED hereby makes, constitutes and appoints Lisa A. Kraeutler and Nicole Vitullo (each an “Attorney”), with full power of substitution, each 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 (the “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 13(g) of the Securities Exchange Act of 1934 and the rules and regulations thereunder, and any other 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 13(g) and said rules and regulations.
This Power of Attorney shall remain in effect until a written revocation thereof is filed with the Commission.
Dated: January 22, 2016
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DOMAIN PARTNERS VII, LP
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By:
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One Palmer Square Partners VII, LLC, its General Partner
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By:
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/s/ James C. Blair
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James C. Blair, Managing Member
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