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*
888 SEVENTH AVENUE, 30TH FLOOR |
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(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 09/03/2013
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3. Issuer Name and Ticker or Trading Symbol
SafeStitch Medical, Inc.
[ SFES.OB ]
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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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Common Stock |
24,088,496 |
I |
By Aisling Capital III, LP
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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 |
1. Name and Address of Reporting Person*
888 SEVENTH AVENUE, 30TH FLOOR |
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(Street)
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1. Name and Address of Reporting Person*
888 SEVENTH AVENUE, 30TH FLOOR |
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(Street)
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1. Name and Address of Reporting Person*
888 SEVENTH AVENUE, 30TH FLOOR |
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(Street)
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1. Name and Address of Reporting Person*
888 SEVENTH AVENUE, 30TH FLOOR |
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(Street)
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1. Name and Address of Reporting Person*
888 SEVENTH AVENUE, 30TH FLOOR |
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(Street)
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1. Name and Address of Reporting Person*
888 SEVENTH AVENUE, 30TH FLOOR |
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(Street)
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Explanation of Responses: |
Remarks: |
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/s/ Lloyd Appel, Aisling Capital III, LP |
09/03/2013 |
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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 99
Form 3 Joint Filer Information
Name: Aisling Capital Partners III, LP
Address: 888 Seventh Avenue, 30th Floor
New York, NY 10106
Designated Filer: Aisling Capital III LP
Issuer & Ticker Symbol: SafeStitch Medical, Inc. (SFES.OB)
Date of Event Requiring Statement: 09/03/2013
Signature: /s/ Lloyd Appel, Aisling Capital Partners III, LP, as general
partner of Aisling Capital III, LP
Name: Aisling Capital Partners III LLC
Address: 888 Seventh Avenue, 30th Floor
New York, NY 10106
Designated Filer: Aisling Capital III LP
Issuer & Ticker Symbol: SafeStitch Medical, Inc. (SFES.OB)
Date of Event Requiring Statement: 09/03/2013
Signature: /s/ Lloyd Appel, Aisling Capital Partners III LLC, as general
partner of Aisling Capital Partners III, LP
Name: Andrew N. Schiff
Address: 888 Seventh Avenue, 30th Floor
New York, NY 10106
Designated Filer: Aisling Capital III LP
Issuer & Ticker Symbol: SafeStitch Medical, Inc. (SFES.OB)
Date of Event Requiring Statement: 09/03/2013
Signature: /s/ Andrew N. Schiff
Name: Dennis J. Purcell
Address: 888 Seventh Avenue, 30th Floor
New York, NY 10106
Designated Filer: Aisling Capital III LP
Issuer & Ticker Symbol: SafeStitch Medical, Inc. (SFES.OB)
Date of Event Requiring Statement: 09/03/2013
Signature: /s/ Dennis J. Purcell
Name: Steve Elms
Address: 888 Seventh Avenue, 30th Floor
New York, NY 10106
Designated Filer: Aisling Capital III LP
Issuer & Ticker Symbol: SafeStitch Medical, Inc. (SFES.OB)
Date of Event Requiring Statement: 09/03/2013
Signature: /s/ Steve Elms