SEC FORM
3
SEC Form 3
| FORM 3 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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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| OMB APPROVAL |
| OMB Number: |
3235-0104 |
| Estimated average burden |
| hours per response: |
0.5 |
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1. Name and Address of Reporting Person*
| C/O ADAPTIVE BIOTECHNOLOGIES CORP. |
| 1165 EASTLAKE AVE E |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
10/28/2021
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3. Issuer Name and Ticker or Trading Symbol
Adaptive Biotechnologies Corp
[ ADPT ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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Director |
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10% Owner |
| X |
Officer (give title below) |
|
Other (specify below) |
| Principal Accounting Officer |
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5. If Amendment, Date of Original Filed
(Month/Day/Year)
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6. Individual or Joint/Group Filing (Check Applicable Line)
| X |
Form filed by One Reporting Person |
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Form filed by More than One Reporting Person |
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| Table I - Non-Derivative Securities Beneficially Owned |
|---|
| 1. Title of Security (Instr.
4)
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2.
Amount of Securities Beneficially Owned (Instr.
4)
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3. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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4. Nature of Indirect Beneficial Ownership (Instr.
5)
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| Common Stock |
2,862 |
D |
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Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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|---|
| 1. Title of Derivative Security (Instr.
4)
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2. Date Exercisable and Expiration Date
(Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr.
4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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6. Nature of Indirect Beneficial Ownership (Instr.
5)
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| Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
| Stock Option (Right to Buy) |
|
11/08/2026 |
Common Stock |
2,500 |
6.32 |
D |
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| Stock Option (Right to Buy) |
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10/01/2028 |
Common Stock |
11,980 |
6.55 |
D |
|
| Stock Option (Right to Buy) |
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04/23/2029 |
Common Stock |
3,750 |
7.8 |
D |
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| Stock Option (Right to Buy) |
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11/14/2029 |
Common Stock |
4,900 |
27.29 |
D |
|
| Stock Option (Right to Buy) |
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02/27/2030 |
Common Stock |
13,474 |
28.32 |
D |
|
| Stock Option (Right to Buy) |
|
09/24/2030 |
Common Stock |
15,000 |
45.82 |
D |
|
| Stock Option (Right to Buy) |
|
03/04/2031 |
Common Stock |
7,154 |
43.68 |
D |
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| Explanation of Responses: |
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| Remarks: |
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/s/ Kyle Piskel by Eric Billings, Attorney in Fact |
11/03/2021 |
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** 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
5
(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). |
| Note: File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure. |
| Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. |
ADAPTIVE BIOTECHNOLOGIES CORPORATION
LIMITED POWER OF ATTORNEY
FOR SECTION 16(a) REPORTING
KNOW ALL PERSONS BY THESE PRESENTS, that the undersigned hereby makes,
constitutes and appoints Chad Cohen and Eric Billings as the
undersigned's true and lawful attorney-in-fact (the "Attorney-in-Fact"), with
full power of substitution and resubstitution, each with the power to act alone
for the undersigned and in the undersigned's name, place and stead, in any and
all capacities to:
1. Prepare, execute, deliver and file with the United States Securities and
Exchange Commission, any national securities exchange and Adaptive
Biotechnologies Corporation (the "Company") any and all reports (including any
amendment thereto) of the undersigned required or considered advisable under
Section 16(a) of the Exchange Act, and the rules and regulations thereunder,
with respect to the equity securities of the Company, including Form 3 (Initial
Statement of Beneficial Ownership of Securities), Form 4 (Statement of Changes
in Beneficial Ownership), and Form 5 (Annual Statement of Changes in Beneficial
Ownership); and
2. Seek or obtain, as the undersigned's representative and on the
undersigned's behalf, information on transactions in the Company's equity
securities from any third party, including the Company, brokers, dealers,
employee benefit plan administrators and trustees, and the undersigned hereby
authorizes any such third party to release any such information to the Attorney-
in-Fact.
The undersigned acknowledges that:
1. This Limited Power of Attorney authorizes, but does not require, the
Attorney-in-Fact to act at his or her discretion on information provided to such
Attorney-in-Fact without independent verification of such information;
2. Any documents prepared and/or executed by the Attorney-in-Fact on behalf
of the undersigned pursuant to this Limited Power of Attorney will be in such
form and will contain such information as the Attorney-in-Fact, in his or her
discretion, deems necessary or desirable;
3. Neither the Company nor the Attorney-in-Fact assumes any liability for
the undersigned's responsibility to comply with the requirements of Section 16
of the Exchange Act, any liability of the undersigned for any failure to comply
with such requirements, or any liability of the undersigned for disgorgement of
profits under Section 16(b) of the Exchange Act; and
4. This Limited Power of Attorney does not relieve the undersigned from
responsibility for compliance with the undersigned's obligations under Section
16 of the Exchange Act, including, without, limitation, the reporting
requirements under Section 16(a) of the Exchange Act.
The undersigned hereby grants to the Attorney-in-Fact full power and
authority to do and perform each and every act and thing requisite, necessary or
convenient to be done in connection with the foregoing, as fully, to all intents
and purposes, as the undersigned might or could do in person, hereby ratifying
and confirming all that the Attorney-in-Fact, or his or her substitute or
substitutes, shall lawfully do or cause to be done by authority of this Limited
Power of Attorney.
This Limited Power of Attorney shall remain in full force and effect until
the undersigned is no longer required to file Forms 3, 4 or 5 with respect to
the undersigned's holdings of and transactions in equity securities of the
Company, and shall only be revoked upon the earliest of (i) revocation by the
undersigned in a signed writing delivered to the Attorney-in-Fact or to the
Secretary of the Company, (ii) termination of the undersigned's service as an
employee or director (as applicable) of the Company, (iii) termination of the
Attorney-in-Fact's service as an officer or other employee of the Company, or
(iv) execution of a subsequent power of attorney by the undersigned which
specifically provides for the revocation of any prior power of attorney
regarding reporting requirements under Section 16(a) of the Exchange Act .
This Limited Power of Attorney shall be governed and construed in accordance
the laws of the State of Washington without regard to the laws that might
otherwise govern under applicable principles of conflicts of laws thereof.
IN WITNESS WHEREOF, the undersigned has caused this Limited Power of
Attorney to be executed as of November 1, 2021.
Signature: /s/ Kyle Piskel
Name: Kyle Piskel
