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*
Xinos Jaime
(Last) (First) (Middle)
22722 29TH DR SE
SUITE 100
(Street)
BOTHELL WA 98021
(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
10/15/2024 		3. Issuer Name and Ticker or Trading Symbol
ACHIEVE LIFE SCIENCES, INC. [ ACHV ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director 10% Owner
X Officer (give title below) Other (specify below)
Chief Commercial Officer
 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 26,293 D
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) (1) 08/01/2027 Common Stock 1,370 578 D
Stock Option (right to buy) (2) 07/26/2028 Common Stock 1,000 67.4 D
Stock Option (right to buy) (3) 09/20/2028 Common Stock 1,850 51.2 D
Stock Option (right to buy) (4) 01/29/2029 Common Stock 2,000 28.4 D
Stock Option (right to buy) (5) 01/28/2030 Common Stock 10,000 11.2 D
Stock Option (right to buy) (6) 11/16/2030 Common Stock 12,000 10.36 D
Stock Option (right to buy) (7) 01/26/2031 Common Stock 25,000 13.09 D
Stock Option (right to buy) (8) 01/03/2032 Common Stock 22,500 8.26 D
Stock Option (right to buy) (9) 01/25/2033 Common Stock 32,500 4.9 D
Stock Option (right to buy) (10) 01/22/2034 Common Stock 21,000 4.55 D
Explanation of Responses:
1. The options are fully vested.
2. The options are fully vested.
3. The options are fully vested.
4. The options are fully vested.
5. The options are fully vested.
6. The options are fully vested.
7. The options vest 25% on the first anniversary of January 26, 2021 and thereafter in monthly installments over 36 months.
8. The options vest one-third on the first anniversary of January 3, 2022 and thereafter in monthly installments over 24 months.
9. The options vest one-third on the anniversary of January 25, 2023 and thereafter in monthly installments over 24 months.
10. The options vest one-third on the first anniversary of January 22, 2024 and thereafter in monthly installments over 24 months.
Sandra Thomson Attorney-in-Fact for Jaime Xinos 10/25/2024
** 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.