Initial Statement of Beneficial Ownership (3)
28 Julio 2017 - 3:24PM
Edgar (US Regulatory)
FORM 3
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0104
Estimated average burden
hours per response...
0.5
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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
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Frazier Life Sciences VIII, L.P.
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2. Date of Event Requiring Statement (MM/DD/YYYY)
7/24/2017
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3. Issuer Name
and
Ticker or Trading Symbol
ALPINE IMMUNE SCIENCES, INC. [ALPN]
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(Last)
(First)
(Middle)
601 UNION STREET, SUITE 3200
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4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director
___
X
___ 10% Owner
_____ Officer (give title below)
_____ Other (specify below)
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(Street)
SEATTLE, WA 98101
(City)
(State)
(Zip)
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5. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
___ 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
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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
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2199011
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D
(1)
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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 Derivate Security
(Instr. 4)
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2. Date Exercisable and Expiration Date
(MM/DD/YYYY)
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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 of Derivative Security: 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
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Expiration Date
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Title
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Amount or Number of Shares
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Explanation of Responses:
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(1)
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This report is filed jointly by Frazier Life Sciences VIII, L.P. ("FLS-VIII"), FHM Life Sciences VIII, L.P. (FHM-VIII L.P."), FHM Life Sciences VIII, L.L.C. ("FHM-VIII LLC") and Patrick J. Heron. Shares are held directly by FLS-VIII. FHM-VIII L.P. serves as the sole general partner of FLS-VIII and owns no shares directly. FHM-VIII LLC serves as the sole general partner of FHM VIII L.P. and owns no shares directly. Mr. Heron and James Topper are members of FHM-VIII LLC and share voting and dispositive power over the shares held by FLS-VIII; however, they disclaim beneficial ownership of the shares held by FLS-VIII except to the extent of their pecuniary interests therein.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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Frazier Life Sciences VIII, L.P.
601 UNION STREET, SUITE 3200
SEATTLE, WA 98101
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X
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FHM LIFE SCIENCES VIII, L.P.
601 UNION STREET, SUITE 3200
SEATTLE, WA 98101
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X
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FHM LIFE SCIENCES VIII, L.L.C.
601 UNION STREET, SUITE 3200
SEATTLE, WA 98101
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X
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Heron Patrick J
601 UNION STREET, SUITE 3200
SEATTLE, WA 98101
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X
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Signatures
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By: FHM Life Sciences VIII, L.P., its general partner, By FHM Life Sciences VIII, L.L.C., its general partner, By: /s/ Steve Bailey, Chief Financial Officer
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7/28/2017
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**
Signature of Reporting Person
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Date
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By: FHM Life Sciences VIII, L.L.C., its general partner, By: /s/ Steve Bailey, Chief Financial Officer
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7/28/2017
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**
Signature of Reporting Person
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Date
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By: /s/ Steve Bailey, Chief Financial Officer
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7/28/2017
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**
Signature of Reporting Person
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Date
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/s/ Patrick J. Heron
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7/28/2017
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 5(b)(v).
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**
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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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Note:
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File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure.
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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 control number.
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