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
|
| 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 ACCESS INDUSTRIES, INC. |
| 40 WEST 57TH STREET, 28TH FLOOR |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
12/29/2022
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3. Issuer Name and Ticker or Trading Symbol
Disc Medicine, Inc.
[ IRON ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
|
Director |
X |
10% Owner |
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Officer (give title below) |
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Other (specify below) |
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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)
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Form filed by One Reporting Person |
| X |
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)
|
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 |
2,706,976 |
D
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Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
|
|---|
| 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)
|
6. Nature of Indirect Beneficial Ownership (Instr.
5)
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| Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
1. Name and Address of Reporting Person*
| C/O ACCESS INDUSTRIES, INC. |
| 40 WEST 57TH STREET, 28TH FLOOR |
(Street)
|
1. Name and Address of Reporting Person*
| C/O ACCESS INDUSTRIES, INC. |
| 40 WEST 57TH STREET, 28TH FLOOR |
(Street)
|
1. Name and Address of Reporting Person*
| C/O ACCESS INDUSTRIES, INC. |
| 40 WEST 57TH STREET, 28TH FLOOR |
(Street)
|
1. Name and Address of Reporting Person*
| C/O ACCESS INDUSTRIES, INC. |
| 40 WEST 57TH STREET, 28TH FLOOR |
(Street)
|
| Explanation of Responses: |
|
| Remarks: |
|
|
/s/ Alejandro Moreno for AI DMI LLC |
01/09/2023 |
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/s/ Alejandro Moreno for Access Industries Holdings LLC |
01/09/2023 |
|
/s/ Alejandro Moreno for Access Industries Management, LLC |
01/09/2023 |
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/s/ Alejandro Moreno as Attorney-in-Fact for Mr. Blavatnik |
01/09/2023 |
|
** 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. |
LIMITED POWER OF ATTORNEY
Know all by these presents, that the undersigned hereby constitutes and appoints
Lincoln Benet and Alejandro Moreno, and each of them individually, the
undersigned's true and lawful attorney-in-fact to:
execute for and on behalf of the undersigned, in the undersigned's capacity as
a beneficial owner of Disc Medicine, Inc. (the "Company"), (i) Forms 3, 4 and 5
and any other forms required to be filed in accordance with Section 16(a) of the
Securities Exchange Act of 1934, as amended (the "Exchange Act") and the rules
thereunder (a "Section 16 Form"), (ii) all forms and schedules in accordance
with Section 13(d) of the Exchange Act and the rules thereunder, including all
amendments thereto (a "Section 13 Schedule"), (iii) a Form ID Application,
Passphrase Update Application and/or request to convert from paper only to
electronic filer with the U.S. Securities and Exchange Commission and to obtain
access codes to file on EDGAR and any other forms required to be filed or
submitted in accordance with Regulation S-T promulgated by the U.S. Securities
and Exchange Commission (or any successor provision) in order to file a Section
13 Schedule or a Section 16 Form electronically (a "Form ID", and, together with
a Section 13 Schedule and Section 16 Form, the "Forms and Schedules") and (iv)
any Joint Filing Agreement or similar agreement with respect to the filing of
any of the Forms or Schedules in (i) through (iii) above;
do and perform any and all acts for and on behalf of the undersigned which may
be necessary or desirable to complete and execute any such Forms and Schedules,
complete and execute any amendment or amendments thereto, and timely file such
Forms and Schedules with the U.S. Securities and Exchange Commission and any
stock exchange or similar authority; and
take any other action of any type whatsoever in connection with the foregoing
which, in the opinion of each such attorney-in-fact, may be of benefit to, in
the best interest of, or legally required by, the undersigned, it being
understood that the documents executed by each such attorney-in-fact on behalf
of the undersigned pursuant to this Limited Power of Attorney shall be in such
form and shall contain such terms and conditions as he may approve in his
discretion.
The undersigned hereby grants to each such attorney-in-fact full power and
authority to do and perform any and every act and thing whatsoever requisite,
necessary or proper to be done in the exercise of any of the rights and powers
herein granted, as fully to all intents and purposes as the undersigned might or
could do if personally present, with full power of substitution or revocation,
hereby ratifying and confirming all that each such attorney-in-fact, or his
substitute or substitutes, shall lawfully do or cause to be done by virtue of
this Limited Power of Attorney and the rights and powers herein granted.
The undersigned acknowledges that each such attorney-in-fact is serving in such
capacity at the request of the undersigned, and is not assuming, nor is the
Company assuming, any of the undersigned's responsibilities to comply with
Section 13 or Section 16 of the Exchange Act.
The Limited Power of Attorney shall remain in full force and effect until the
undersigned is no longer required to file any Forms and Schedules with respect
to the undersigned's holdings of and transactions in securities issued by the
Company, unless earlier revoked by the undersigned in a signed writing delivered
to each such attorney-in-fact.
From and after the date hereof, any Limited Power of Attorney previously granted
by the undersigned concerning the subject matter hereof is hereby revoked.
IN WITNESS WHEREOF, the undersigned has executed this Limited Power of Attorney
as of January 9, 2023.
LEONARD BLAVATNIK
/s/ Leonard Blavatnik
