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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1. Name and Address of Reporting Person*
ROBINS CHAD M

(Last) (First) (Middle)
C/O ADAPTIVE BIOTECHNOLOGIES CORPORATION
1551 EASTLAKE AVE E STE 200

(Street)
SEATTLE WA 98102

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
06/26/2019
3. Issuer Name and Ticker or Trading Symbol
Adaptive Biotechnologies Corp [ ADPT ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director 10% Owner
X Officer (give title below) Other (specify below)
CEO and Chairman
5. 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 Beneficially Owned
1. Title of Security (Instr. 4) 2. Amount of Securities Beneficially Owned (Instr. 4) 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 4. Nature of Indirect Beneficial Ownership (Instr. 5)
Common Stock 1,787,500 D
Common Stock 2,237,500(1) I By South Dakota Trust Company, Trustee of the Harlan Robins 2017 Trust
Common Stock 500,000(1) I By HSR 2014 Mother's Trust U/T/A dated June 17, 2014
Common Stock 350,000(1) I By HSR 2017 Trust for Descendants, u/a/d November 10, 2017
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 4) 2. Date Exercisable and Expiration Date (Month/Day/Year) 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) 4. Conversion or Exercise Price of Derivative Security 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 6. Nature of Indirect Beneficial Ownership (Instr. 5)
Date Exercisable Expiration Date Title Amount or Number of Shares
Stock Option (Right to Buy) (2) 12/20/2021 Common Stock 800,000 0.33 D
Stock Option (Right to Buy) (2) 06/09/2025 Common Stock 800,000 6.32 D
Stock Option (Right to Buy) (3) 02/07/2028 Common Stock 600,000 6.55 D
Stock Option (Right to Buy) (4) 02/07/2029 Common Stock 410,000 7.27 D
Series E-1 Preferred Stock (5) (5) Common Stock 70,680 0.0(5) D
Explanation of Responses:
1. The reporting person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein.
2. The option is fully vested and exercisable.
3. The options vested with respect to 1/4 of such shares on November 1, 2018, with 1/48 of such shares vesting thereafter at the end of each full month of continuous service until fully vested.
4. The options vest with respect to 1/4 of such shares on January 1, 2020, with 1/48 of such shares vesting thereafter at the end of each full month of continuous service until fully vested.
5. The shares of preferred stock will convert immediately upon the closing of an initial public offering of the Issuer's common stock on a one-for-one basis and have no expiration date.
/s/ Chad M Robins by Stacy Taylor, Attorney-in-Fact 06/26/2019
** 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.
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