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*
| C/O SILVERBACK THERAPEUTICS, INC. |
| 500 FAIRVIEW AVENUE N, SUITE 600 |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
12/03/2020
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3. Issuer Name and Ticker or Trading Symbol
Silverback Therapeutics, Inc.
[ SBTX ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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Director |
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10% Owner |
| X |
Officer (give title below) |
|
Other (specify below) |
| Sr. Vice President of Finance |
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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)
| X |
Form filed by One Reporting Person |
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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)
|
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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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 |
| Stock option (right to buy) |
|
04/28/2030 |
Common Stock |
57,808 |
1.27 |
D |
|
| Stock option (right to buy) |
|
04/28/2030 |
Common Stock |
17,619 |
1.27 |
D |
|
| Stock option (right to buy) |
|
04/28/2030 |
Common Stock |
18,269 |
1.27 |
D |
|
| Stock option (right to buy) |
|
09/30/2030 |
Common Stock |
26,932 |
6.65 |
D |
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| Explanation of Responses: |
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|
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| Remarks: |
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/s/ Jeffrey C. Pepe, Attorney-in-Fact |
12/03/2020 |
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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. |
LIMITED POWER OF ATTORNEY
FOR SECTION 16(a) FILINGS
Know all by these presents, that the undersigned hereby constitutes and appoints
each of Jeffrey C. Pepe and Jonathan Piazza, signing individually, as the
undersigned's true and lawful attorney-in fact to:
(1) Execute for and on behalf of the undersigned, in the undersigned's capacity
as an officer, director and/or stockholder of Silverback Therapeutics, Inc. (the
"Company"), Forms 3, 4, and 5 and amendments thereto in accordance with Section
16(a) of the Securities Exchange Act of 1934, as amended (the "Exchange Act")
and the rules thereunder;
(2) Do and perform any and all acts for and on behalf of the undersigned which
may be necessary or desirable to complete and execute any such Form 3, 4, or 5,
or amendment thereto and timely file such form with the United States Securities
and Exchange Commission (the "SEC") and any stock exchange or similar authority;
and
(3) Take any other action of any type whatsoever which, in the opinion of any
such attorney-in-fact, may be necessary or desirable in connection with the
foregoing authority, it being understood that the documents executed by such
attorney-in-fact on behalf of the undersigned pursuant to this Limited Power of
Attorney shall be in such form and shall contain such terms and conditions as
such attorney-in-fact may approve in such attorney-in-facts discretion.
The undersigned hereby grants to each such attorney-in-fact full power and
authority to do and perform any and every act and thing whatsoever required,
necessary, or proper to be done in the exercise of any of the rights and powers
herein granted, as fully to all intents and purposes as the undersigned might or
could do if personally present, with full power of substitution or revocation,
hereby ratifying and confirming all that such attorney-in-fact, or such
attorney-in-fact's substitute or substitutes, shall lawfully do or cause to be
done by virtue of this Limited Power of Attorney and the rights and powers
herein granted. The undersigned acknowledges that each of the foregoing
attorneys-in-fact, in serving in such capacity at the request of the
undersigned, is not assuming, nor is the Company assuming, any of the
undersigned's responsibilities to comply with Section 16 of the Exchange Act.
This Limited Power of Attorney shall remain in full force and effect until the
earlier to occur of (a) undersigned is no longer required to file Forms 3, 4 and
5 with respect to any securities issued by the Company, (b) revocation by the
undersigned in a signed writing delivered to the foregoing attorney-in-fact and
(c) as to any attorney in fact individually until such attorney-in-fact is no
longer employed by the Company. This Limited Power of Attorney may be filed
with the SEC as a confirming statement of the authority granted herein.
IN WITNESS WHEREOF, the undersigned has caused this Limited Power of Attorney to
be executed as of November 22, 2020.
/s/ Russ Hawkinson
