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 | ||||
Seies F Preferred Stock | 12/24/2008 | Â (1) | Common Stock | 9,375 | $ (1) | I | By the Matthew J. Revord Declaration of Trust dated June 30, 2013 |
Stock Options (right to buy) | Â (2) | 01/08/2017 | Common Stock | 100,000 | $ 8 | D | Â |
Stock Options (right to buy) | Â (2) | 05/14/2018 | Common Stock | 20,000 | $ 8 | D | Â |
Stock Options (right to buy) | Â (2) | 01/22/2019 | Common Stock | 30,000 | $ 8 | D | Â |
Stock Options (right to buy) | Â (2) | 08/05/2019 | Common Stock | 5,849 | $ 8 | D | Â |
Stock Options (right to buy) | Â (2) | 07/01/2020 | Common Stock | 7,000 | $ 7 | D | Â |
Stock Options (right to buy) | Â (3) | 05/10/2021 | Common Stock | 49,427 | $ 7.22 | D | Â |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
REVORD MATTHEW J C/O POTBELLY CORPORATION 222 MERCHANDISE MART PLAZA, 23RD FLOOR CHICAGO, IL 60654 |
 |  |  SVP, GC and Secretary |  |
/s/Matthew J. Revord | 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) | The Series F 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 F Preferred Stock will automatically covert into common stock on a 1-to-1 basis upon the closing of Potbelly's initial public offering. |
(2) | All stock options have vested and become exercisable upon the closing of Potbelly's initial public offering. |
(3) | All stock options have vested and are exercisable. |