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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT OF CHANGES IN 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. | |||
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. | SEC 1474 (9-02) |
1. Title of Derivative Security (Instr. 3) |
2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) |
5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4, and 5) |
6. Date Exercisable and Expiration Date (Month/Day/Year) |
7. Title and Amount of Underlying Securities (Instr. 3 and 4) |
8. Price of Derivative Security (Instr. 5) |
9. Number of Derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) |
10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
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Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||||||
Series B Preferred Stock | $ 0 (1) | 10/09/2013 | C | 1,000,000 | 09/18/2002 | (1) | Common Stock | 1,000,000 (2) | $ 0 | 0 | I | See footnote (2) | |||
Series C Preferred Stock | $ 0 (3) | 10/09/2013 | C | 401,481 | 10/08/2003 | (3) | Common Stock | 404,941 (2) | $ 0 | 0 | I | See footnote (2) | |||
Series D Preferred Stock | $ 0 (4) | 10/09/2013 | C | 145,833 | 03/23/2005 | (4) | Common Stock | 149,737 (2) | $ 0 | 0 | I | See footnote (2) | |||
Series E Preferred Stock | $ 0 (5) | 10/09/2013 | C | 17,857 | 02/13/2006 | (5) | Common Stock | 18,479 (2) | $ 0 | 0 | I | See footnote (2) | |||
Series F Preferred Stock | $ 0 (6) | 10/09/2013 | C | 25,000 | 12/29/2008 | (6) | Common Stock | 25,000 (2) | $ 0 | 0 | I | See footnote (2) |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
BENCHMARK CAPITAL MANAGEMENT CO IV LLC 2480 SAND HILL ROAD SUITE 200 MENLO PARK, CA 94025 |
X | |||
BENCHMARK FOUNDERS FUND IV LP 2480 SAND HILL RD. #200 MENLO PARK, CA 94025 |
X | |||
BENCHMARK FOUNDERS FUND IV A LP 2480 SAND HILL RD. #200 MENLO PARK, CA 94025 |
X | |||
BENCHMARK FOUNDERS FUND IV-B LP 2480 SAND HILL RD. #200 MENLO PARK, CA 94025 |
X | |||
BENCHMARK CAPITAL PARTNERS IV LP 2480 SAND HILL RD. #200 MENLO PARK, CA 94025 |
X | |||
HARVEY KEVIN 2480 SAND HILL ROAD SUITE 200 MENLO PARK, CA 94025 |
X | |||
SPURLOCK STEVEN M 3820 SAND HILL ROAD SUITE 200 MENLO PARK, CA 94025 |
X | |||
GURLEY J WILLIAM 3820 SAND HILL ROAD SUITE 200 MENLO PARK, CA 94025 |
X | |||
KAGLE ROBERT 3820 SAND HILL ROAD SUITE 200 MENLO PARK, CA 94025 |
X | |||
DUNLEVIE BRUCE 2480 SAND HILL ROAD SUITE 200 MENLO PARK, CA 94025 |
X |
/s/Steven M. Spurlock, as Managing Member of Benchmark Capital Management Co. IV, LLC | 10/11/2013 | |
**Signature of Reporting Person | Date | |
/s/Steven M. Spurlock, as Managing Member of Benchmark Capital Management Co. IV, LLC, the General Partner of Benchmark Capital Partners IV, L.P. | 10/11/2013 | |
**Signature of Reporting Person | Date | |
/s/Steven M. Spurlock, as Managing Member of Benchmark Capital Management Co. IV, LLC, as the General Partner of Benchmark Founders' Fund IV, L.P. | 10/11/2013 | |
**Signature of Reporting Person | Date | |
/s/Steven M. Spurlock, as Managing Member of Benchmark Capital Management Co. IV, LLC, as the General Partner of Benchmark Founders' Fund IV-A, L.P. | 10/11/2013 | |
**Signature of Reporting Person | Date | |
/s/Steven M. Spurlock, as Managing Member of Benchmark Capital Management Co. IV, LLC, as the General Partner of Benchmark Founders' Fund IV-B, L.P. | 10/11/2013 | |
**Signature of Reporting Person | Date | |
/s/Steven M. Spurlock, by power of attorney for Kevin R. Harvey | 10/11/2013 | |
**Signature of Reporting Person | Date | |
/s/Steven M. Spurlock, by power of attorney for Bruce W. Dunlevie | 10/11/2013 | |
**Signature of Reporting Person | Date | |
/s/Steven M. Spurlock, by power of attorney for J. William Gurley | 10/11/2013 | |
**Signature of Reporting Person | Date | |
/s/Steven M. Spurlock, by power of attorney for Robert C. Kagle | 10/11/2013 | |
**Signature of Reporting Person | Date | |
/s/Steven M. Spurlock | 10/11/2013 | |
**Signature of Reporting Person | Date |
* | If the form is filed by more than one reporting person, see Instruction 4(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 B Preferred Stock automatically converted into Potbelly Corporation ("Potbelly") common stock on a 1-to-1 basis upon the closing of Potbelly's initial public offering and did not have an expiration date. |
(2) | Represents shares held by Benchmark Capital Partners IV, L.P., as nominee for Benchmark Capital Partners IV, L.P., Benchmark Founders' Fund IV, L.P., Benchmark Founders' Fund IV-A, L.P., Benchmark Founders' Fund IV-B, L.P. and related individuals (collectively, the "Benchmark Funds"). Benchmark Capital Management Co. IV, L.L.C. ("BCMC IV") is the general partner of Benchmark Capital Partners IV, L.P. and BCMC IV's managing members are Bruce W. Dunlevie, J. William Gurley, Kevin R. Harvey, Robert C. Kagle and Steven Spurlock. These individuals may be deemed to beneficially own the shares held by the Benchmark Funds. Each of these individuals disclaims beneficial ownership of such shares except to the extent of such individuals pecuniary interest therein. |
(3) | The Series C Preferred Stock automatically converted into Potbelly common stock on a 1-to-1.0086 basis upon the closing of Potbelly's initial public offering and did not have an expiration date. |
(4) | The Series D Preferred Stock automatically converted into Potbelly common stock on a 1-to-1.0268 basis upon the closing of Potbelly's initial public offering and did not have an expiration date. |
(5) | The Series E Preferred Stock automatically converted into Potbelly common stock on a 1-to-1.0348 basis upon the closing of Potbelly's initial public offering and did not have an expiration date. |
(6) | The Series F Preferred Stock automatically converted into Potbelly common stock on a 1-to-1 basis upon the closing of Potbelly's initial public offering and did not have an expiration date. |
Remarks: Bruce W. Dunlevie, J. William Gurley, Kevin R. Harvey, Robert C. Kagle and Steven M. Spurlock are the managing members of Benchmark Capital Management Co IV, L.L.C., which serves as general partner to Benchmark Capital Partners IV, L.P., Benchmark Founders' Fund IV, Benchmark Founders Fund IV-A, L.P. and Benchmark Founders Fund IV-B, L.P. and may be deemed to share voting and investment power over the shares beneficially held by such entities. Each such person and entity disclaims the existence of a "group" and disclaims beneficial ownership of any securities (except to the extent of such person's or entity's pencuniary interest in such securities) other than any securities being reported herein as being directly owned by such person or entity. The filing of this report is not an admission that any Reporting Person is the beneficial owners of these shares for purposes of Section 16 or for any other purpose. |