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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1. Name and Address of Reporting Person*
Eclipse GP III, LLC

(Last) (First) (Middle)
514 HIGH STREET
SUITE 4

(Street)
PALO ALTO CA 94301

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
02/04/2021
3. Issuer Name and Ticker or Trading Symbol
Lucira Health, Inc. [ LHDX ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director X 10% Owner
Officer (give title below) Other (specify below)
5. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
Form filed by One Reporting Person
X Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Beneficially Owned
1. Title of Security (Instr. 4) 2. Amount of Securities Beneficially Owned (Instr. 4) 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 4. Nature of Indirect Beneficial Ownership (Instr. 5)
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 4) 2. Date Exercisable and Expiration Date (Month/Day/Year) 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) 4. Conversion or Exercise Price of Derivative Security 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 6. Nature of Indirect Beneficial Ownership (Instr. 5)
Date Exercisable Expiration Date Title Amount or Number of Shares
Series A Preferred Stock (1) (1) Common Stock 976,852 (1) I See footnote(2)
Series B Preferred Stock (1) (1) Common Stock 877,445 (1) I See footnote(2)
Series C Preferred Stock (1) (1) Common Stock 185,512 (1) I See footnote(2)
Series C Preferred Stock (1) (1) Common Stock 3,710,257 (1) D(3)
Convertible Promissory Note (4) 12/11/2022 Common Stock 473,729 13.6 D(3)
1. Name and Address of Reporting Person*
Eclipse GP III, LLC

(Last) (First) (Middle)
514 HIGH STREET
SUITE 4

(Street)
PALO ALTO CA 94301

(City) (State) (Zip)
1. Name and Address of Reporting Person*
Eclipse Ventures Fund I, L.P.

(Last) (First) (Middle)
514 HIGH STREET
SUITE 4

(Street)
PALO ALTO CA 94301

(City) (State) (Zip)
1. Name and Address of Reporting Person*
Eclipse Fund III, L.P.

(Last) (First) (Middle)
514 HIGH STREET
SUITE 4

(Street)
PALO ALTO CA 94301

(City) (State) (Zip)
1. Name and Address of Reporting Person*
Eclipse Ventures GP I, LLC

(Last) (First) (Middle)
514 HIGH STREET
SUITE 4

(Street)
PALO ALTO CA 94301

(City) (State) (Zip)
Explanation of Responses:
1. Each share of Series A Preferred Stock, Series B Preferred Stock, and Series C Preferred Stock (the "Preferred Stock") automatically converts on a one-for-one basis into Common Stock upon the closing of the Issuer's initial public offering (the "IPO"), for no additional consideration. The shares of Preferred Stock have no expiration date.
2. The securities are held directly by Eclipse Ventures Fund I, L.P. ("Eclipse I"). Eclipse Ventures GP I, LLC ("Eclipse I GP") is the general partner of Eclipse I and may be deemed to have voting and dispositive power over the shares held by Eclipse I. Mr. Susan, a member of the Issuer's board of directors, is the sole managing member of Eclipse I GP and may be deemed to have voting and dispositive power over the shares held by Eclipse I. Eclipse I GP and Mr. Susan disclaim beneficial ownership of the shares held by Eclipse I except to the extent of their respective pecuniary interests therein, if any.
3. The securities are held directly by Eclipse Fund III, L.P. ("Eclipse III"). Eclipse GP III, LLC ("Eclipse III GP") is the general partner of Eclipse III and may be deemed to have voting and dispositive power over the shares held by Eclipse III. Mr. Susan, a member of the Issuer's board of directors, is the sole managing member of Eclipse III GP and may be deemed to have voting and dispositive power over the shares held by Eclipse III. Eclipse III GP and Mr. Susan disclaim beneficial ownership of the shares held by Eclipse III except to the extent of their respective pecuniary interests therein, if any.
4. The convertible promissory note will automatically convert into shares of the Issuer's Common Stock upon the closing of the IPO.
Remarks:
Eclipse GP III, LLC /s/ Lior Susan, Managing Member 02/04/2021
Eclipse Ventures Fund I, L.P. By: Eclipse Ventures GP I, LLC, its General Partner /s/ Lior Susan, Managing Member 02/04/2021
Eclipse Fund III, L.P., By: Eclipse GP III, LC, its General Partner, /s/ Lior Susan, Managing Member 02/04/2021
Eclipse Ventures GP I, LLC /s/ Lior Susan, Managing Member 02/04/2021
** 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).
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