Sec Form 4 Filing - BLANK SIMONE @ Evolus, Inc. - 2021-02-05

Insider filing report for Changes in Beneficial Ownership
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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
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person
BLANK SIMONE
2. Issuer Name and Ticker or Trading Symbol
Evolus, Inc. [ EOLS]
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)
520 NEWPORT CENTER DR., SUITE 1200
3. Date of Earliest Transaction (MM/DD/YY)
02/05/2021
(Street)
NEWPORT BEACH, CA92660
4. If Amendment, Date Original Filed (MM/DD/YY)
6. Individual or Joint/Group Filing (Check Applicable Line)
__ X __ Form filed by One Reporting Person
_____ Form filed by More than One Reporting Person
(City) (State) (Zip)
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1.Title of Security
(Instr. 3)
2. Transaction Date (MM/DD/YY) 2A. Deemed Execution Date, if any (MM/DD/YY) 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 02/05/2021 A 19,313 ( 1 ) A $ 0 19,313 D
Common Stock 367,577 ( 2 ) I See Footnote
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 (MM/DD/YY) 3A. Deemed Execution Date, if any (MM/DD/YY) 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
(MM/DD/YY)
7. Title and Amount of Underlying Securities
(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
Reporting Owners
Reporting Owner Na me / Address Relationships
Director 10% Owner Officer Other
BLANK SIMONE
520 NEWPORT CENTER DR.
SUITE 1200
NEWPORT BEACH, CA92660
X
Signatures
/s/ Jeffrey J. Plumer, as attorney-in-fact for Simone Blank 02/12/2021
Signature of Reporting Person Date
Explanation of Responses:
( 1 )Represents shares issuable on settlement of restricted stock units ("RSUs") granted to the reporting person. Each RSU represents a contingent right to receive one share of the Issuer's common stock. The RSUs will vest in full on the one year anniversary of February 5, 2021, provided the reporting person remains in continuous service before the vesting date, subject to accelerated vesting in certain events, including upon certain changes of control of the Issuer.
( 2 )Reflects the contribution in October 2020 of all shares of common stock of the Issuer held by Dental Innovations BVBA ("DI") to Dental Innovations Apus Investment BV ("DIAI) and to Dental Innovations Investment A BV. The Reporting Person, as a shareholder of DI, previously reported beneficial ownership of all 923,560 shares held by DI; however, the Reporting Person had a pecuniary interest in only 367,577 of such shares. As the sole beneficial owner of DIAI, the Reporting Person continues to have a pecuniary interest in the 367,577 shares contributed to DIAI. Accordingly, the transaction represents only a change in the form of beneficial ownership without changing the Reporting Person's pecuniary interest in such shares and, as a result, the transaction was exempt from Section 16 of the Securities Exchange Act of 1934, as amended

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* If the form is filed by more than one reporting person, see Instruction 4(b)(v).
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