Sec Form 4 Filing - PROEHL GERALD T @ Dermata Therapeutics, Inc. - 2021-08-16

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
PROEHL GERALD T
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 X __ 10% Owner
X __ Officer (give title below) _____ Other (specify below)
President, CEO and Chairman
(Last) (First) (Middle)
3525 DEL MAR HEIGHTS RD., #332
3. Date of Earliest Transaction (MM/DD/YY)
08/16/2021
(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 08/16/2021 P 10,000 A $ 4.9631 ( 1 ) 10,000 I By Proehl Family Trust ( 8 )
Common Stock 08/17/2021 C 17,857 A 17,857 I By Allison Taylor Proehl 2020 Irrevocable Trust ( 8 )
Common Stock 08/17/2021 C 8,928 A 8,928 I By Meghan Proehl Wilder 2020 Irrevocable Trust ( 8 )
Common Stock 08/17/2021 C 35,767 A 35,767 I By Sean Michael Proehl 2020 Irrevocable Trust Dated December 18, 2020 ( 8 )
Common Stock 08/17/2021 C 361,147 A 1,278,464 I By Proehl Investment Ventures LLC ( 8 )
Common Stock 08/17/2021 C 111,951 A 1,390,415 I By Proehl Investment Ventures LLC ( 8 )
Common Stock 08/17/2021 C 181,585 A 1,572,000 I By Proehl Investment Ventures LLC ( 8 )
Common Stock 08/17/2021 C 1,247,904 A 2,819,904 I By Proehl Investment Ventures LLC ( 8 )
Common Stock 08/17/2021 C 85,640 A 2,905,544 I By Proehl Investment Ventures LLC ( 8 )
Common Stock 08/17/2021 P 142,857 A 152,857 I By Proehl Family Trust ( 8 )
Common Stock 39,512 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
Series 1d Preferred Stock ( 2 ) 08/17/2021 C 120,481 ( 2 ) ( 2 ) Common Stock 17,857 $ 0 0 I By Allison Taylor Proehl 2020 Irrevocable Trust ( 8 )
Series 1d Preferred Stock ( 2 ) 08/17/2021 C 60,240 ( 2 ) ( 2 ) Common Stock 8,928 $ 0 0 I By Meghan Proehl Wilder 2020 Irrevocable Trust ( 8 )
Series 1d Preferred Stock ( 2 ) 08/17/2021 C 241,325 ( 2 ) ( 2 ) Common Stock 35,767 $ 0 0 I By Sean Michael Proehl 2020 Irrevocable Trust Dated December 18, 2020 ( 8 )
Series 1d Preferred Stock ( 2 ) 08/17/2021 C 2,436,657 ( 2 ) ( 2 ) Common Stock 361,147 $ 0 0 I By Proehl Investment Ventures LLC ( 8 )
Series 1a Preferred Stock ( 3 ) 08/17/2021 C 2,295,000 ( 3 ) ( 3 ) Common Stock 111,951 $ 0 0 I By Proehl Investment Ventures LLC ( 8 )
Series 1b Preferred Stock ( 4 ) 08/17/2021 C 3,722,500 ( 4 ) ( 4 ) Common Stock 181,585 $ 0 0 I By Proehl Investment Ventures LLC ( 8 )
Series 1c Preferred Stock ( 5 ) 08/17/2021 C 25,582,050 ( 5 ) ( 5 ) Common Stock 1,247,904 $ 0 0 I By Proehl Investment Ventures LLC ( 8 )
Series 1 Preferred Stock ( 6 ) 08/17/2021 C 1,755,622 ( 6 ) ( 6 ) Common Stock 85,640 $ 0 0 I By Proehl Investment Ventures LLC ( 8 )
Series 1a Warrants ( 7 ) 08/17/2021 C 573,750 11/15/2016 03/14/2026 Common Stock 27,987 $ 0 0 I By Proehl Investment Ventures LLC ( 8 )
Warrant to Purchase Common Stock $ 20.5 08/17/2021 C 27,987 11/15/2016 03/14/2026 Common Stock 27,987 $ 0 27,987 I By Proehl Investment Ventures LLC ( 8 )
Warrant to Purchase Common Stock $ 7 08/17/2021 P 142,857 08/17/2021 08/17/2026 Common Stock 142,857 ( 9 ) 142,857 I By Proehl Family Trust ( 8 )
Reporting Owners
Reporting Owner Name / Address Relationships
Director 10% Owner Officer Other
PROEHL GERALD T
3525 DEL MAR HEIGHTS RD., #332
SAN DIEGO, CA92130
X X President, CEO and Chairman
Signatures
/s/ Gerald T. Proehl 08/17/2021
Signature of Reporting Person Date
Explanation of Responses:
( 1 )The price reported in Column 4 is a weighted average price. These shares were purchased in multiple transactions at prices ranging from $4.84 to $5.00 per share, inclusive. The Reporting Person undertakes to provide to the Issuer, any security holder of the Issuer, or the staff of the Securities and Exchange Commission, upon request, full information regarding the number of shares purchased at each separate price within the ranges set forth herein.
( 2 )The Series 1d Preferred Stock automatically converted into Common Stock of the Issuer upon consummation of the Issuer's initial public offering (the "IPO"). The Series 1d Preferred Stock was convertible at any time and had no expiration date.
( 3 )The Series 1a Preferred Stock converted into Common Stock of the Issuer upon consummation of the IPO. The Series 1a Preferred Stock was convertible at any time and had no expiration date.
( 4 )The Series 1b Preferred Stock converted into Common Stock of the Issuer upon consummation of the IPO. The Series 1b Preferred Stock was convertible at any time and had no expiration date.
( 5 )The Series 1c Preferred Stock converted into Common Stock of the Issuer upon consummation of the IPO. The Series 1c Preferred Stock was convertible at any time and had no expiration date.
( 6 )The Series 1 Preferred Stock converted into Common Stock of the Issuer upon consummation of the IPO. The Series 1 Preferred Stock was convertible at any time and had no expiration date.
( 7 )The Series 1a Preferred Warrants converted into warrants to purchase Common Stock in connection with the IPO.
( 8 )Reporting Person disclaims beneficial ownership of these securities except to the extent of their pecuniary interest therein, and the inclusion of these shares in this report shall not be deemed an admission of beneficial ownership of all of the reported shares for purposes of Section 16 or for any other purpose.
( 9 )Reporting Person purchased 142,857 Units in the IPO at $7.00 per Unit Each Unit consists of one share of Common Stock and one warrant to purchase one share of Common Stock.

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