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*
JEFFS ROGER

(Last) (First) (Middle)
C/O AXSOME THERAPEUTICS, INC.
200 BROADWAY, 3RD FLOOR

(Street)
NEW YORK NY 10038

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
Axsome Therapeutics, Inc. [ AXSM ]
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)
07/03/2019
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 07/03/2019 M 3,672(1) A $3.67 3,672 D
Common Stock 07/03/2019 M 39,948(1) A $2.85 43,620 D
Common Stock 07/03/2019 M 13,000(1) A $3.45 56,620 D
Common Stock 46,912 I GRAT(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
Stock Option (Right to Buy) $3.67 07/03/2019 M 3,672 (2) 09/15/2024 Common Stock 3,672(1) $0 7,344(2) D
Stock Option (Right to Buy) $2.85 07/03/2019 M 39,948 03/12/2018 03/11/2028 Common Stock 39,948(1) $0 0 D
Stock Option (Right to Buy) $3.45 07/03/2019 M 13,000 06/01/2019 06/01/2028 Common Stock 13,000(1) $0 0 D
Explanation of Responses:
1. The Reporting Person has elected to exercise and hold the shares at this time.
2. Reflects a partial option exercise by the Reporting Person. This option was granted on September 16, 2014. 3,672 shares subject to the option became fully vested and exercisable on September 16, 2015. The remaining 7,344 shares subject to the option, which were not exercised by the Reporting Person, became fully vested and exercisable in equal annual installments on the second and third anniversaries of the date of grant.
3. Represents additional shares held indirectly by the Reporting Person prior to July 3, 2019.
/s/ Herriot Tabuteau, M.D., Attorney-in-Fact 07/05/2019
** 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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