Statement of Changes in Beneficial Ownership (4)
28 December 2021 - 08:32AM
Edgar (US Regulatory)
FORM 4
[ ]
Check this box if no longer subject to Section 16. Form 4 or Form 5
obligations may continue. See Instruction 1(b).
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL
OWNERSHIP OF SECURITIES
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APPROVAL
OMB Number: 3235-0287
Estimated average burden
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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 * Drapeau Louis |
2. Issuer Name and Ticker or Trading
Symbol AVITA Medical, Inc. [ RCEL ] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)__X__
Director _____
10% Owner
_____ Officer (give title
below) _____ Other
(specify below)
|
(Last)
(First)
(Middle)
C/O AVITA THERAPEUTICS, INC., 28159 AVENUE STANFORD, SUITE
220 |
3. Date of Earliest Transaction (MM/DD/YYYY)
12/22/2021
|
(Street)
VALENCIA, CA 91355
(City)
(State)
(Zip)
|
4. If Amendment, Date Original Filed
(MM/DD/YYYY)
|
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. Trans. Date |
2A. Deemed Execution Date, if any |
3. Trans. 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 |
12/22/2021 |
|
A |
|
4350 |
A |
(1) |
4689 (2)(3) |
D |
|
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible
securities)
|
1. Title of Derivate Security
(Instr. 3) |
2. Conversion or Exercise Price of Derivative
Security |
3. Trans. Date |
3A. Deemed Execution Date, if any |
4. Trans. 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 |
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 of Derivative Security: 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 |
Stock Options (Right to
Buy) |
$12.18 |
12/22/2021 |
|
A |
|
2550 |
|
(4) |
12/22/2031 |
Common Stock |
2550 |
$0.00 |
2550 |
D |
|
Explanation of
Responses: |
(1) |
Represents an award of
Restricted Stock Units ("RSUs"), each representing a contingent
right to be issued one share of Common Stock, that are subject to
time-based vesting criteria. These RSUs vest on the date 12 months
following the grant date. |
(2) |
Includes 1,695 of the
Issuer's CHESS Depositary Interests ("CDIs"). CDIs are units of
beneficial ownership in shares of common stock of the Issuer that
are publicly traded on the Australian Securities Exchange (the
"ASX") and held by CHESS Depositary Nominees Pty, Limited, a
subsidiary of ASX Limited, the company that operates the ASX. Five
CDIs are equivalent to one share of Common Stock and have all the
rights and privileges of Common Stock. The Reporting Person holds
1,695 CDIs, which translate into 339 of the shares of Common Stock
set forth above |
(3) |
Includes unvested
RSUs. |
(4) |
These Stock Options vest on
the date 12 months following the grant date. |
Reporting
Owners
|
Reporting Owner Name / Address |
Relationships
|
Director |
10% Owner |
Officer |
Other |
Drapeau Louis
C/O AVITA THERAPEUTICS, INC.
28159 AVENUE STANFORD, SUITE 220
VALENCIA, CA 91355 |
X |
|
|
|
Signatures
|
/s/ Donna Shiroma, by power of
attorney |
|
12/27/2021 |
**Signature of Reporting
Person |
Date |
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