Exhibit 10.4

 

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NUMBER
SBW
CAPNIA, INC.
CORPORATE
SEAL
AUGUST 25, 1999
DELAWARE
THIS WARRANT SHALL BE VOID IF NOT EXERCISED PRIOR TO THE EXPIRATION OF THE
EXERCISE PERIOD PROVIDED FOR IN THE WARRANT AGREEMENT DESCRIBED BELOW
Series B Warrant Certificate
C A P N I A
INCORPORATED UNDER THE LAWS OF THE STATE
OF DELAWARE
SEE REVERSE FOR CERTAIN DEFINITIONS
This Series B Warrant Certificate certifies that, or registered assigns, is the
record holder of
warrant(s) (the “Warrants “ and each, a “ Warrant “) to purchase shares of
Common Stock, no par value (“ Common Stock “), of Capnia, Inc., a Delaware
corporation (the “ Company “). Each Warrant entitles the holder, upon exercise
during the period set forth in the Warrant Agreement referred to below, to
receive from the Company that number of fully paid and nonassessable shares of
Common Stock as set forth below, at the exercise price (the “Exercise Price “)
as determined pursuant to the Warrant Agreement, payable in lawful money (or
through “ cashless exercise “ as provided for in the Warrant Agreement) of the
United States of America upon surrender of this
Warrant Certificate and payment of the Exercise Price at the office or agency of
the Warrant Agent referred to below, subject to the conditions set forth herein
and in the Warrant Agreement. Defined terms used in this Warrant Certificate but
not defined herein shall have the meanings given to them in the Warrant
Agreement (as defined on the reverse hereof).
Each Warrant is initially exercisable for one fully paid and non-assessable
share of Common Stock. The number of the shares of Common Stock issuable upon
exercise of the Warrants is subject to adjustment upon the occurrence of certain
events set forth in the Warrant Agreement.
The initial Exercise Price per share of Common Stock for any Warrant is equal to
$ per share. The Exercise Price is subject to adjustment upon the occurrence of
certain events set forth in the Warrant Agreement. Subject to the conditions set
forth in the Warrant Agreement, the Warrants may be exercised only during the
Exercise Period and to the extent not exercised by the end of such Exercise
Period, such Warrants shall become void. Reference is hereby made to the further
provisions of this Warrant Certificate set forth on the reverse hereof and such
further provisions shall for all purposes have the same effect as though fully
set forth at this place. This Warrant Certificate shall not be valid unless
countersigned by the Warrant Agent, as such term is used in the Warrant
Agreement.
This Warrant Certificate shall be governed by and construed in accordance with
the internal laws of the State of New York, without regard to conflicts of laws
principles thereof.
COUNTERSIGNED AND REGISTERED:
Dated: AMERICAN STOCK TRANSFER & TRUST COMPANY, LLC
(NEW YORK, NY) WARRANT AGENT
BY:
AUTHORIZED SIGNATURE
PRESIDENT SECRETARY

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The Warrants evidenced by this Warrant Certificate are part of a duly authorized
issue of Warrants entitling the holder on exercise to receive shares of Common
Stock and are issued or to be issued pursuant to a Warrant Agreement dated as of
, 2014 (the “ Warrant Agreement “), duly executed and delivered by the Company
to , as warrant agent (the “ Warrant Agent “), which Warrant Agreement is hereby
incorporated by reference in and made a part of this instrument and is hereby
referred to for a description of the rights, limitation of rights, obligations,
duties and immunities thereunder of the Warrant Agent, the Company and the
holders (the words “ holders “ or “ holder “ meaning the Registered Holders or
Registered Holder) of the Warrants. A copy of the Warrant Agreement may be
obtained by the holder hereof upon written request to the Company. Defined terms
used in this Warrant Certificate but not defined herein shall have the meanings
given to them in the Warrant Agreement.
Warrants may be exercised at any time during the Exercise Period set forth in
Section 3.3 of the Warrant Agreement.
Notwithstanding anything else in this Warrant Certificate or the Warrant
Agreement, no Warrant may be exercised unless at the time of exercise (i) a
registration statement covering the shares of Common Stock to be issued upon
exercise is effective under the Securities Act and (ii) a prospectus thereunder
relating to the shares of Common Stock is current, except through “cashless
exercise “ as provided for in the Warrant Agreement. The Warrant Agreement
provides that upon the occurrence of certain events the number of shares of
Common Stock issuable upon exercise of the Warrants set forth on the face hereof
may, subject to certain conditions, be adjusted. If, upon exercise of a Warrant,
the holder thereof would be entitled to receive a fractional interest in a share
of Common Stock, the Company shall, upon exercise, round up to the nearest whole
number of shares of Common Stock to be issued to the holder of the Warrant.
Warrant Certificates, when surrendered at the principal corporate trust office
of the Warrant Agent by the Registered Holder thereof in person or by legal
representative or attorney duly authorized in writing, may be exchanged, in the
manner and subject to the limitations provided in the Warrant Agreement, but
without payment of any service charge, for another Warrant Certificate or
Warrant Certificates of like tenor evidencing in the aggregate a like number of
Warrants.
Upon due presentation for registration of transfer of this Warrant Certificate
at the office of the Warrant Agent a new Warrant Certificate or Warrant
Certificates of like tenor and evidencing in the aggregate a like number of
Warrants shall be issued to the transferee(s) in exchange for this Warrant
Certificate, subject to the limitations provided in the Warrant Agreement,
without charge except for any tax or other governmental charge imposed in
connection therewith.
The Company and the Warrant Agent may deem and treat the Registered Holder(s)
hereof as the absolute owner(s) of this Warrant Certificate (notwithstanding any
notation of ownership or other writing hereon made by anyone), for the purpose
of any exercise hereof, of any distribution to the holder(s) hereof, and for all
other purposes, and neither the Company nor the Warrant Agent shall be affected
by any notice to the contrary. Neither the Warrants nor this Warrant Certificate
entitles any holder hereof to any rights of a stockholder of the Company.
Election to Purchase
(To Be Executed Upon Exercise of Warrant)
The undersigned hereby irrevocably elects to exercise the right, represented by
this Warrant Certificate, to receive shares of Common Stock and herewith tenders
payment for such shares to the order of Capnia, Inc. (the “ Company “) in the
amount of $ in accordance with the terms hereof. The undersigned requests that a
certificate for such shares be registered in the name of , whose address is and
that such shares be delivered to whose address is . If said number of shares is
less than all of the shares of Common Stock purchasable hereunder, the
undersigned requests that a new Warrant Certificate representing the remaining
balance of such shares be registered in the name of , whose address is , and
that such Warrant Certificate be delivered to , whose address is .
In the event that the Warrant is to be exercised on a “cashless” basis pursuant
to Section 3.3.2 of the Warrant Agreement, the number of shares that this
Warrant is exercisable for shall be determined in accordance with Section 3.3.2
of the Warrant Agreement.
a “Cash Exercise” with respect to Warrant Shares; and/or
a “Cashless Exercise” with respect to Warrant Shares, resulting in a delivery
obligation by the Company to the Holder of shares of Common Stock representing
the applicable Net Number and, if applicable, Market Price Net Number, subject
to adjustment.
In the event that the Warrant may be exercised, to the extent allowed by the
Warrant Agreement, through cashless exercise (i) the number of shares that this
Warrant is exercisable for would be determined in accordance with the relevant
section of the Warrant Agreement which allows for such cashless exercise and
(ii) the holder hereof shall complete the following: The undersigned hereby
irrevocably elects to exercise the right, represented by this Warrant
Certificate, through the cashless exercise provisions of the Warrant Agreement,
to receive shares of Common Stock. If said number of shares is less than all of
the shares of Common Stock purchasable hereunder (after giving effect to the
cashless exercise), the undersigned requests that a new Warrant Certificate
representing the remaining balance of such shares be registered in the name of ,
whose address is , and that such Warrant Certificate be delivered to , whose
address is . whose address is .
Signature: Tax Identification Number: Date:
ASSIGNMENT
(To assign the foregoing Warrant, execute this form and supply required
information. Do not use this form to purchase shares. Assignment of the Warrant
is subject to applicable law.)
FOR VALUE RECEIVED, the foregoing Warrant and all rights evidenced thereby are
hereby assigned to:
Name Address Signed: By: Title: Date:
NOTE: The assignor on this Assignment Form must correspond with the name as it
appears on the face of the Warrant, without alteration or enlargement or any
change whatever. Officers of corporations and those acting in a fiduciary or
other representative capacity should provide proper evidence of authority to
assign the foregoing Warrant.
Signature(s) Guaranteed:
By
THE SIGNATURE(S) SHOULD BE GUARANTEED BY AN ELIGIBLE GUARANTOR INSTITUTION,
(BANKS, STOCKBROKERS, SAVINGS AND LOAN ASSOCIATIONS AND CREDIT UNIONS WITH
MEMBERSHIP IN AN APPROVED SIGNATURE GUARANTEE MEDALLION PROGRAM), PURSUANT TO
S.E.C. RULE 17AD-15.