Sec Form 3 Filing - WIERENGA WENDELL @ Dermata Therapeutics, Inc. - 2021-08-12

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
WIERENGA WENDELL
2. Issuer Name and Ticker or Trading Symbol
Dermata Therapeutics, Inc. [ DRMA]
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)
3525 DEL MAR HEIGHTS RD., #332
3. Date of Earliest Transaction (MM/DD/YY)
08/12/2021
(Street)
SAN DIEGO, CA92130
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 4,878 ( 1 ) D
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
Stock Option (Right to Buy) $ 5.74 03/31/2021 03/31/2031 Common Stock 12,194 ( 1 ) D
Stock Option (Right to Buy) $ 5.74 ( 2 ) 03/31/2031 Common Stock 4,878 ( 1 ) D
Series 1d Preferred Stock ( 3 ) ( 3 ) ( 3 ) Common Stock 55,078 ( 3 ) D
Reporting Owners
Reporting Owner Name / Address Relationships
Director 10% Owner Officer Other
WIERENGA WENDELL
3525 DEL MAR HEIGHTS RD., #332
SAN DIEGO, CA92130
X
Signatures
/s/ Gerald T. Proehl, Attorney-in Fact 08/12/2021
Signature of Reporting Person Date
Explanation of Responses:
( 1 )Shares reported reflect the 1 for 20.5 stock split effected July 1, 2021 (the "Stock Split").
( 2 )Options vest in 12 equal monthly installments commencing January 1, 2021.
( 3 )The Series 1d Preferred Stock is convertible into shares of Common Stock at a conversion ratio equal to 80% of the offering price in connection with the Issuer's initial public offering ("IPO"). Upon filing of the Issuer's Restated Certificate of Incorporation in connection with the IPO, all shares of Series 1d Preferred Stock will be converted into 8,163 shares of Common Stock of the Issuer. The conversion ratio reflects the Stock Split.

Remarks:
Exhibit 24. Power of Attorney

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