Sec Form 3 Filing - Yen Tuff @ Lucira Health, Inc. - 2021-02-04

Insider filing report for Changes in Beneficial Ownership
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FORM 3
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
Yen Tuff
2. Issuer Name and Ticker or Trading Symbol
Lucira Health, Inc. [ LHDX]
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)
1412 62ND STREET
3. Date of Earliest Transaction (MM/DD/YY)
02/04/2021
(Street)
EMERYVILLE, CA94608
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
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
Series A Preferred Stock ( 1 ) ( 1 ) ( 1 ) Common Stock 416,069 I See footnote ( 2 )
Series B Preferred Stock ( 1 ) ( 1 ) ( 1 ) Common Stock 737,489 I See footnote ( 2 )
Series C Preferred Stock ( 1 ) ( 1 ) ( 1 ) Common Stock 951,885 I See footnote ( 3 )
Convertible Promissory Note $ 13.6 ( 4 ) 12/11/2022 Common Stock 74,637 I See footnote ( 2 )
Convertible Promissory Note $ 13.6 ( 4 ) 12/11/2022 Common Stock 61,588 I See footnote ( 3 )
Stock Option (right to buy) $ 0.82 ( 5 ) 06/19/2029 Common Stock 51,334 I See footnote ( 6 )
Reporting Owners
Reporting Owner Name / Address Relationships
Director 10% Owner Officer Other
Yen Tuff
1412 62ND STREET
EMERYVILLE, CA94608
X
Signatures
/s/ Dan George, Attorney-in-Fact for Tuff Yen 02/04/2021
Signature of Reporting Person Date
Explanation of Responses:
( 1 )Each share of Series A Preferred Stock, Series B Preferred Stock, and Series C Preferred Stock (the "Preferred Stock") automatically converts on a one-for-one basis into Common Stock upon the closing of the Issuer's initial public offering (the "IPO"), for no additional consideration. The shares of Preferred Stock have no expiration date.
( 2 )The securities are held directly by Seraph Diassess, LLC. Seraph Group LLC is the manager of Seraph Diassess, LLC and exercises investment and voting control over the shares held by Seraph Diassess, LLC. All investment decisions are made by Mr. Yen in his capacity as the President of Seraph Diassess, LLC. Mr. Yen disclaims beneficial ownership of the shares held by Seraph Diassess, LLC except to the extent of his pecuniary interest therein, if any.
( 3 )The securities are held directly by Seraph Investments II, LLC. Seraph Group LLC is the manager of Seraph Investments II, LLC and exercises investment and voting control over the shares held by Seraph Investments II, LLC. All investment decisions are made by Mr. Yen in his capacity as the Manager of Seraph Investments II, LLC. Mr. Yen disclaims beneficial ownership of the shares held by Seraph Investments II, LLC except to the extent of his pecuniary interest therein, if any.
( 4 )The convertible promissory note will automatically convert into shares of the Issuer's Common Stock upon the closing of the IPO.
( 5 )The shares subject to the option are immediately exercisable. 1/24th of the shares subject to the option shall vest monthly over the two years from the vesting commencement date.
( 6 )The securities are held directly by Seraph Group LLC. Mr. Yen is the president of Seraph Group LLC. All investment decisions are made by Mr. Yen in his capacity as the President of Seraph Group, LLC. Mr. Yen disclaims beneficial ownership of the shares held by Seraph Group, LLC except to the extent of his pecuniary interest therein, if any.

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