UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | SEC 1473 (7-02) | ||
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 control number. |
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 of Derivative Security: Direct (D) or Indirect (I) (Instr. 5) |
6. Nature of Indirect Beneficial Ownership (Instr. 5) |
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Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Series B Preferred Stock | 09/18/2002 | Â (2) | Common Stock | 1,000,000 (3) | $ (2) | D | Â |
Series C Preferred Stock | 10/08/2003 | Â (4) | Common Stock | 404,941 (3) | $ (4) | D | Â |
Series D Preferred Stock | 03/23/2005 | Â (5) | Common Stock | 187,484 (3) | $ (5) | D | Â |
Series E Preferred Stock | 02/13/2006 | Â (6) | Common Stock | 382,442 (3) | $ (6) | D | Â |
Series F Preferred Stock | 12/24/2008 | Â (7) | Common Stock | 258,152 (3) | $ (7) | D | Â |
Series F Preferred Stock | 01/27/2009 | Â (7) | Common Stock | 100,000 (3) | $ (7) | D | Â |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
OAK INVESTMENT PARTNERS IX L P 3890 WELLS FARGO CENTER 90 SOUTH 7TH STREET MINNEAPOLIS, MN 55402 |
 |  X |  |  |
OAK IX AFFILIATES FUND LP 3890 WELLS FARGO CENTER 90 SOUTH 7TH STREET MINNEAPOLIS, MN 55402 |
 |  X |  |  |
OAK IX AFFILIATES FUND A LP 3890 WELLS FARGO CENTER 90 SOUTH 7TH STREET MINNEAPOLIS, MN 55402 |
 |  X |  |  |
/s/ | 10/03/2013 | |
**Signature of Reporting Person | Date |
* | 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). |
(1) | Includes shares held by Oak Investment Partners IX, Limited Partnership ("Oak Investment"), Oak IX Affiliates Fund, Limited Partnership ("Oak IX Fund") and Oak IX Affiliates Fund-A, Limited Partnership ("Oak IX Fund-A"). Oak Associates IX, L.L.C., as the general partner of Oak Investment, and Oak IX Affiliates, L.L.C., as the general partner of each of Oak IX Fund and Oak IX Fund-A, may be deemed to beneficially own these shares. Each of Oak Associates IX, L.L.C. and Oak IX Affiliates, L.L.C. disclaims beneficial ownership of the shares reported herein except to the extent of its pecuniary interest therein. |
(2) | The Series B Preferred Stock is convertible into Potbelly Corporation ("Potbelly") common stock on a 1-to-1 basis at the option of the holder and has no expiration date. The Series B Preferred Stock will automatically convert into common stock on a 1-to-1 basis upon the closing of Potbelly's initial public offering. |
(3) | Includes shares held by Oak Investment, Oak IX Fund and Oak IX Fund-A. See Footnote 1. |
(4) | The Series C Preferred Stock is convertible into Potbelly common stock on a 1-to-1.0086 basis at the option of the holder and has no expiration date. The Series C Preferred Stock will automatically convert into common stock on a 1-to-1.0086 basis upon the closing of Potbelly's initial public offering. |
(5) | The Series D Preferred Stock is convertible into Potbelly common stock on a 1-to-1.0268 basis at the option of the holder and has no expiration date. The Series D Preferred Stock will automatically convert into common stock on a 1-to-1.0268 basis upon the closing of Potbelly's initial public offering. |
(6) | The Series E Preferred Stock is convertible into Potbelly common stock on a 1-to-1.0348 basis at the option of the holder and has no expiration date. The Series E Preferred Stock will automatically convert into common stock on a 1-to-1.0348 basis upon the closing of Potbelly's initial public offering. |
(7) | The Series F Preferred Stock is convertible into Potbelly common stock on a 1-to-1 basis at the option of the holder and has no expiration date. The Series F Preferred Stock will automatically convert into common stock on a 1-to-1 basis upon the closing of Potbelly's initial public offering. |