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) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
Series A Preferred Stock
|
09/19/2001 |
Â
(2)
|
Common Stock
|
500,000
|
$
(2)
|
I
|
by: Oxford Blackpoint Venture Partners VII, LLC (see Footnote 1)
|
Series B Preferred Stock
|
09/18/2002 |
Â
(3)
|
Common Stock
|
142,892
|
$
(3)
|
I
|
by: Oxford Blackpoint Venture Partners VII, LLC (see Footnote 1)
|
Series C Preferred Stock
|
10/08/2003 |
Â
(4)
|
Common Stock
|
109,270
|
$
(4)
|
I
|
by: Oxford Blackpoint Venture Partners VII, LLC (see Footnote 1)
|
Series D Preferred Stock
|
03/23/2005 |
Â
(5)
|
Common Stock
|
161,288
|
$
(5)
|
I
|
See footnote
(6)
|
Series E Preferred Stock
|
02/13/2006 |
Â
(7)
|
Common Stock
|
280,879
|
$
(7)
|
I
|
See footnote
(8)
|
Series F Preferred Stock
|
12/24/2008 |
Â
(9)
|
Common Stock
|
82,927
|
$
(9)
|
I
|
by: Oxford Blackpoint Venture Partners VII, LLC (see Footnote 1)
|
Common Stock Warrants (right to buy)
|
05/28/2012 |
Â
(10)
|
Common Stock
|
241,704
|
$
8.16
|
I
|
by: Oxford Capital Partners, Inc. (see Footnote 1)
|
* |
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 Oxford Blackpoint Venture Partners VII, LLC ("Oxford Blackpoint") and Concorde Holdings IX, LLC ("Concorde"). Oxford Blackpoint is an investment fund managed by Oxford Capital Partners, Inc. ("Oxford Capital"). Mr. Avedisian is co-owner of Oxford Capital and the sole owner of Concorde. Accordingly, Mr. Avedisian may be deemed to share power to vote and dispose of shares owned directly by such entities. Mr. Avedisian disclaims beneficial ownership of such shares except to the extent of his pecuniary interest therein. |
(2) |
The Series A 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 A Preferred Stock will automatically convert into common stock on a 1-to-1 basis upon the closing of Potbelly's initial public offering. |
(3) |
The Series B 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 B Preferred Stock will automatically convert into common stock on a 1-to-1 basis upon the closing of Potbelly's initial public offering. |
(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) |
Includes shares held by Oxford Blackpoint and Concorde. See Footnote 1. |
(7) |
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. |
(8) |
Includes shares held by Oxford Blackpoint and Concorde. See Footnote 1. |
(9) |
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. |
(10) |
Oxford Capital Partners, Inc. may exercise the warrant at any time prior to the earliest to occur of (i) the fifth anniversary of the closing of Potbelly's initial public offering or (ii) a Liquidity Event (which term generally includes a sale of all or substantially all of Potbelly's assets or a transfer of the voting power to elect a majority of its board of directors through a sale of capital stock or the consummation of a merger or consolidation). |