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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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*
Yen Tuff

(Last) (First) (Middle)
1412 62ND STREET

(Street)
EMERYVILLE CA 94608

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
Lucira Health, Inc. [ LHDX ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director 10% Owner
Officer (give title below) Other (specify below)
3. Date of Earliest Transaction (Month/Day/Year)
02/09/2021
4. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security (Instr. 3) 2. Transaction Date (Month/Day/Year) 2A. Deemed Execution Date, if any (Month/Day/Year) 3. Transaction Code (Instr. 8) 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 7. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V Amount (A) or (D) Price
Common Stock 02/09/2021 C 416,069 A (1) 416,069 I See footnote(2)
Common Stock 02/09/2021 C 737,489 A (1) 1,153,558 I See footnote(2)
Common Stock 02/09/2021 C 74,637 A $13.6 1,228,195 I See footnote(2)
Common Stock 02/09/2021 C 951,885 A (1) 951,885 I See footnote(3)
Common Stock 02/09/2021 C 61,588 A $13.6 1,013,473 I See footnote(3)
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 3) 2. Conversion or Exercise Price of Derivative Security 3. Transaction Date (Month/Day/Year) 3A. Deemed Execution Date, if any (Month/Day/Year) 4. Transaction Code (Instr. 8) 5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) 6. Date Exercisable and Expiration Date (Month/Day/Year) 7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4) 8. Price of Derivative Security (Instr. 5) 9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) 10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 11. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V (A) (D) Date Exercisable Expiration Date Title Amount or Number of Shares
Series A Preferred Stock (1) 02/09/2021 C 416,069 (1) (1) Common Stock 416,069 $0.00 0 I See footnote(2)
Series B Preferred Stock (1) 02/09/2021 C 737,489 (1) (1) Common Stock 737,489 $0.00 0 I See footnote(2)
Convertible Promissory Note $13.6 02/09/2021 C $1,015,065.29 (4) 12/11/2022 Common Stock 74,637 $0.00 0 I See footnote(2)
Series C Preferred Stock (1) 02/09/2021 C 951,885 (1) (1) Common Stock 951,885 $0.00 0 I See footnote(3)
Convertible Promissory Note $13.6 02/09/2021 C $837,603.6 (4) 12/11/2022 Common Stock 61,588 $0.00 0 I See footnote(3)
Explanation of Responses:
1. Each share of Series A Preferred, Series B Preferred Stock and Series C Preferred Stock (the "Preferred Stock") automatically converted on a one-for-one basis into Common Stock at the closing of the Issuer's initial public offering, for no additional consideration. The shares of Preferred Stock had no expiration date.
2. The securities are held directly by Seraph Diassess, LLC. Seraph Group LLC is the manager of Seraph Diassess, LLC and exercises investment and voting control over the shares held by Seraph Diassess, LLC. All investment decisions are made by Mr. Yen in his capacity as the President of Seraph Diassess, LLC. Mr. Yen disclaims beneficial ownership of the shares held by Seraph Diassess, LLC except to the extent of his pecuniary interest therein, if any.
3. The securities are held directly by Seraph Investments II, LLC. Seraph Group LLC is the manager of Seraph Investments II, LLC and exercises investment and voting control over the shares held by Seraph Investments II, LLC. All investment decisions are made by Mr. Yen in his capacity as the Manager of Seraph Investments II, LLC. Mr. Yen disclaims beneficial ownership of the shares held by Seraph Investments II, LLC except to the extent of his pecuniary interest therein, if any.
4. The convertible promissory note automatically converted into shares of the Issuer's Common Stock at the closing of the IPO.
Remarks:
/s/ Dan George, Attorney-in-Fact for Tuff Yen 02/09/2021
** 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 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).
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