SEC FORM 4 SEC Form 4
FORM 4 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
or Section 30(h) of the Investment Company Act of 1940
 
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
1. Name and Address of Reporting Person*
Cui Xiangmin

(Last) (First) (Middle)
C/O CUE HEALTH INC.
4980 CARROLL CANYON RD. SUITE 100

(Street)
SAN DIEGO CA 92121

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
Cue Health Inc. [ HLTH ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director 10% Owner
Officer (give title below) Other (specify below)
3. Date of Earliest Transaction (Month/Day/Year)
09/28/2021
4. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security (Instr. 3) 2. Transaction Date (Month/Day/Year) 2A. Deemed Execution Date, if any (Month/Day/Year) 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 09/28/2021 C 8,192,468 A (1) 8,192,468 I See Footnote(2)
Common Stock 09/28/2021 A(3) 788,441 A $12.8 788,441 I See Footnote(4)
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 (Month/Day/Year) 3A. Deemed Execution Date, if any (Month/Day/Year) 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 (Month/Day/Year) 7. Title and Amount of Securities Underlying Derivative Security (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: 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 C-1 Preferred Stock (1) 09/28/2021 C 8,192,468 (1) (1) Common Stock 8,192,468 $0 0 I See Footnote(2)
Explanation of Responses:
1. On September 28, 2021, the Series C-1 Preferred Stock automatically converted into Common Stock on a one-to-one basis without payment of further consideration upon the closing of the initial public offering of the Issuer's common stock. The shares had no expiration date.
2. The shares are held directly by Decheng Capital China Life Sciences USD Fund III, L.P. (the "Fund"). Decheng Capital Management III (Cayman), LLC (the "GP") is the general partner of the Fund. The reporting person is the manager of the GP and disclaims beneficial ownership of such securities held by the Fund, except to the extent of his pecuniary interest therein, if any.
3. On September 28, 2021, outstanding principal and accrued interest underlying a convertible note automatically converted into Common Stock upon the closing of the initial public offering of the Issuer's common stock at a conversion price equal to 80% of the initial public offering price per share.
4. The shares are held directly by Decheng Capital Global Healthcare Fund (Master), LLC, whose general partner is Decheng Capital Global Healthcare GP, LLC. The reporting person is the sole member and manager of Decheng Capital Global Healthcare GP, LLC. The reporting person disclaims beneficial ownership of these securities, except to the extent of his pecuniary interest therein, if any.
/s/ Erica Palsis, Attorney-in-Fact for Xiangmin Cui 09/30/2021
** 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 4 (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).
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