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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 		 
OMB APPROVAL
OMB Number: 3235-0287
Estimated average burden
hours per response: 0.5
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*
Avista Acquisition Corp.
(Last) (First) (Middle)
C/O AVISTA HEALTHCARE PUBLIC ACQUIS CORP
65 EAST 55TH STREET, 18TH FLOOR
(Street)
NEW YORK NY 10022
(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
Avista Healthcare Public Acquisition Corp. [ AHPA ] 		5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director X 10% Owner
Officer (give title below) Other (specify below)
3. Date of Earliest Transaction (Month/Day/Year)
08/17/2018
4. If Amendment, Date of Original Filed (Month/Day/Year)
 6. Individual or Joint/Group Filing (Check Applicable Line)
Form filed by One Reporting Person
X 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
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
Class B Ordinary Shares (1) 08/17/2018 J(2) 1,423,125 (1) (1) Class A Ordinary Shares 1,423,125 (2) 4,269,375 D(3)(4)(5)
1. Name and Address of Reporting Person*
Avista Acquisition Corp.
(Last) (First) (Middle)
C/O AVISTA HEALTHCARE PUBLIC ACQUIS CORP
65 EAST 55TH STREET, 18TH FLOOR
(Street)
NEW YORK NY 10022
(City) (State) (Zip)
1. Name and Address of Reporting Person*
Avista Acquisition, LLC
(Last) (First) (Middle)
C/O AVISTA HEALTHCARE PUBLIC ACQUIS CORP
65 EAST 55TH STREET, 18TH FLOOR
(Street)
NEW YORK NY 10022
(City) (State) (Zip)
1. Name and Address of Reporting Person*
Dean Thompson
(Last) (First) (Middle)
C/O AVISTA HEALTHCARE PUBLIC ACQUIS CORP
65 EAST 55TH STREET, 18TH FLOOR
(Street)
NEW YORK NY 10022
(City) (State) (Zip)
1. Name and Address of Reporting Person*
Burgstahler David F
(Last) (First) (Middle)
C/O AVISTA HEALTHCARE PUBLIC ACQUIS CORP
65 EAST 55TH STREET, 18TH FLOOR
(Street)
NEW YORK NY 10022
(City) (State) (Zip)
Explanation of Responses:
1. Pursuant to the Amended and Restated Memorandum and Articles of Association (the "Articles") of the Issuer, the Class B ordinary shares, par value $0.0001 per share (the "Class B Shares") will automatically convert into Class A ordinary shares, par value $0.0001 per share, of the Issuer at the time of the Issuer's Business Combination, as defined in the Articles, on a one-for-one basis, subject to adjustment, and have no expiration date.
2. 1,423,125 Class B ordinary shares were forfeited by Avista Acquisition Corp. (the "Sponsor") to the Issuer for no consideration.
3. Directly owned by Sponsor. The sole shareholder of Sponsor is Avista Acquisition, LLC ("Avista Acquisition"). Thompson Dean and David Burgstahler are the managers of Avista Acquisition (and, together with Sponsor, Messrs. Dean and Burgstahler are the "Reporting Persons").
4. Because of the relationship among the Reporting Persons, the Reporting Persons may be deemed to beneficially own the securities reported herein to the extent of their respective pecuniary interests. Each Reporting Person disclaims beneficial ownership of the securities reported herein, except to the extent of such Reporting Person's pecuniary interest therein, if any.
5. Pursuant to Rule 16a-1(a)(4) under the Exchange Act, this filing shall not be deemed an admission that the Reporting Persons are, for purposes of Section 16 of the Exchange Act or otherwise, the beneficial owners of any equity securities in excess of their respective pecuniary interests.
Remarks:
Exhibit 99.1 Joint Filer Information, incorporated herein by reference.
By: /s/ Benjamin Silbert, Attorney-in-Fact for Avista Acquisition Corp. 10/15/2018
By: /s/ Benjamin Silbert, Attorney-in-Fact for Avista Acquisition, LLC. 10/15/2018
By: /s/ Benjamin Silbert, Attorney-in-Fact for Thompson Dean 10/15/2018
By: /s/ Benjamin Silbert, Attorney-in-Fact for David Burgstahler 10/15/2018
** 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).
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.

Exhibit 99.1

 

Joint Filer Information

 

Name of Joint Filer:

 

Avista Acquisition, LLC

 

 

 

Address of Joint Filer:

 

c/o Avista Healthcare Public Acquisition Corp.

 

 

65 East 55th Street

 

 

18th Floor

 

 

New York, NY 10022

 

 

 

Relationship of Joint Filer to Issuer:

 

10% Owner

 

 

 

Issuer Name and Ticker or Trading Symbol:

 

Avista Healthcare Public Acquisition Corp. [AHPA]

 

 

 

Date of Event Requiring Statement:

 

 

(Month/Day/Year):

 

8/17/2018

 

 

 

Designated Filer:

 

Avista Acquisition Corp.

 

 

 

Name of Joint Filer:

 

Thompson Dean

 

 

 

Address of Joint Filer:

 

c/o Avista Healthcare Public Acquisition Corp.

 

 

65 East 55th Street

 

 

18th Floor

 

 

New York, NY 10022

 

 

 

Relationship of Joint Filer to Issuer:

 

Director; 10% Owner; Officer (Executive Chairman)

 

 

 

Issuer Name and Ticker or Trading Symbol:

 

Avista Healthcare Public Acquisition Corp. [AHPA]

 

 

 

Date of Event Requiring Statement:

 

 

(Month/Day/Year):

 

8/17/2018

 

 

 

Designated Filer:

 

Avista Acquisition Corp.

 

 

 

Name of Joint Filer:

 

David Burgstahler

 

 

 

Address of Joint Filer:

 

c/o Avista Healthcare Public Acquisition Corp.

 

 

65 East 55th Street

 

 

18th Floor

 

 

New York, NY 10022

 

 

 

Relationship of Joint Filer to Issuer:

 

Director; 10% Owner; Officer (President and Chief Executive Officer)

 

 

 

Issuer Name and Ticker or Trading Symbol:

 

Avista Healthcare Public Acquisition Corp. [AHPA]

 

 

 

Date of Event Requiring Statement:

 

 

(Month/Day/Year):

 

8/17/2018

 

 

 

Designated Filer:

 

Avista Acquisition Corp.