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*
SEGAL CARL AARON

(Last) (First) (Middle)
C/O POTBELLY CORPORATION
222 MERCHANDISE MART PLAZA, 23RD FLOOR

(Street)
CHICAGO IL 60654

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
10/03/2013
3. Issuer Name and Ticker or Trading Symbol
POTBELLY CORP [ PBPB ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director 10% Owner
X Officer (give title below) Other (specify below)
SVP Operations-Spec Projects
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 1,375 I by: SHK Capital Partners, a partnership controlled by Mr. Segal.
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
Series F Preferred Stock 12/24/2008 (1) Common Stock 13,750 (1) I by: SHK Capital Partners, a partnership controlled by Mr. Segal.
Stock Options (right to buy) (2) 01/01/2014 Common Stock 10,000 $9 D
Stock Options (right to buy) (2) 01/01/2015 Common Stock 15,000 $12 D
Stock Options (right to buy) (2) 11/15/2017 Common Stock 50,000 $10.59 D
Stock Options (right to buy) (2) 05/14/2018 Common Stock 20,000 $8 D
Stock Options (right to buy) (2) 08/05/2019 Common Stock 4,549 $8 D
Stock Options (right to buy) (2) 07/01/2020 Common Stock 4,148 $7 D
Stock Options (right to buy) (2) 01/02/2021 Common Stock 132,692 $7 D
Stock Options (right to buy) (3) 05/10/2021 Common Stock 26,014 $7.22 D
Stock Options (right to buy) (2) 03/05/2023 Common Stock 11,932 $9.47 D
Explanation of Responses:
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.
/s/Matthew J. Revord, Attorney-in-fact 10/03/2013
** 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.