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*
| 8201 E RIVERSIDE DRIVE, BLDG. 4, STE 100 |
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(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
04/14/2015
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3. Issuer Name and Ticker or Trading Symbol
XBiotech Inc.
[ XBIT ]
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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) |
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Other (specify below) |
| VP of Fin & HR, Secretary |
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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)
|
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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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 |
12/10/2006 |
12/09/2016 |
Common Stock |
50,000 |
0.79 |
D |
|
| Stock Option |
04/21/2008 |
04/20/2018 |
Common Stock |
80,000 |
2.5 |
D |
|
| Stock Option |
02/28/2011 |
02/27/2021 |
Common Stock |
20,000 |
7.5 |
D |
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| Stock Option |
12/12/2012 |
12/11/2022 |
Common Stock |
5,000 |
15 |
D |
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| Explanation of Responses: |
| Remarks: |
|
|
/s/ Seth Goettelman under Power of Attorney for Queena Han |
04/14/2015 |
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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. |
POWER OF ATTORNEY
Know all by these presents, that the undersigned hereby constitutes and
appoints Laura Holm, Seth Goettelman or John Simard with full power of
substitution, as the undersigned's true and lawful attorney-in-fact to:
(1) execute for and on behalf of the undersigned, in the
undersigned's capacity as an officer and/or director of XBiotech
Inc. or any successor thereto (the "Company"), Forms 3, 4, and 5
in accordance with Section 16(a) of the Securities Exchange Act
of 1934 and the rules thereunder (the "Exchange Act"), Form 144
in accordance with Rule 144 under the Securities Act of 1933
("Rule 144") and any other forms or reports, including, but not
limited to, a Form ID, that the undersigned may be required to
file in connection with the undersigned's ownership, acquisition
or disposition of securities of the Company;
(2) 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 Form 3, 4 or 5, Form 144 or other form or
report, complete and execute any amendment or amendments thereto
and timely file such form or report with the Securities and
Exchange Commission and any stock exchange or similar authority;
and
(3) take any other action of any type whatsoever in connection with
the foregoing which, in the opinion of 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 such attorney-in-fact on behalf of the
undersigned pursuant to this Power of Attorney shall be in such
form and shall contain such terms and conditions as such
attorney-in-fact may approve in such attorney-in-fact's
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 such
attorney-in-fact, or such attorney-in-fact's substitute or substitutes, shall
lawfully do or cause to be done by virtue of this power of attorney and the
rights and powers herein granted. The undersigned acknowledges that the
foregoing attorneys-in-fact, in serving in such capacity at the request of the
undersigned, are not assuming, nor is the Company assuming, any of the
undersigned's responsibilities to comply with Section 16 of the Exchange Act or
Rule 144.
This Power of Attorney revokes any previous Power of Attorney filed with
the Company for the purposes set forth herein and shall remain in full force and
effect until the undersigned is no longer required to file Forms 3, 4 and 5 with
respect to the undersigned's holdings of and transactions in securities issued
by the Company, unless expressly revoked before that time.
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to
be executed as of this 6th day of April, 2015.
/s/ Queena Han
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Queena Han
