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*
Mitchell Alex

(Last) (First) (Middle)
623 FIFTH AVENUE, 31ST FLOOR

(Street)
NEW YORK NY 10022

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
06/30/2014
3. Issuer Name and Ticker or Trading Symbol
Jason Industries, Inc. [ JASN ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director X 10% Owner
Officer (give title below) Other (specify below)
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 119,799 I See Footnote(1)
Common Stock 539,036 I See Footnote(2)
Common Stock 87,842 I See Footnote(3)
Common Stock 457,255 I See Footnote(4)
Common Stock 26,268 I See Footnote(5)
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
Warrants 08/14/2014 06/30/2019 Common Stock 159,305 $12 I See Footnote(1)
Warrants 08/14/2014 06/30/2019 Common Stock 720,325 $12 I See Footnote(2)
Warrants 08/14/2014 06/30/2019 Common Stock 161,464 $12 I See Footnote(3)
Warrants 08/14/2014 06/30/2019 Common Stock 612,441 $12 I See Footnote(4)
Warrants 08/14/2014 06/30/2019 Common Stock 42,367 $12 I See Footnote(5)
Explanation of Responses:
1. The securities are held by Scopus Partners, L.P. ("SPLP"). The reporting person owns 100% of the equity interests of the general partner of SPLP. The reporting person disclaims pecuniary interest in the reported securities except to the extent of his economic interest.
2. The securities are held by Scopus Partners II, L.P. ("SPIILP"). The reporting person owns 100% of the equity interests of the general partner of SPIILP. The reporting person disclaims pecuniary interest in the reported securities except to the extent of his economic interest.
3. The securities are held by Scopus Vista Partners, L.P. ("SVPLP"). The reporting person owns 100% of the equity interests of the general partner of SVPLP. The reporting person disclaims pecuniary interest in the reported securities except to the extent of his economic interest.
4. The securities are held by Scopus Fund Ltd. ("SFL"). The reporting person owns an equity interest in SFL and indirectly controls SFL. The reporting person disclaims pecuniary interest in the reported securities except to the extent of his economic interest.
5. The securities are held by Scopus Vista Fund Ltd. ("SVFL"). The reporting person owns an equity interest in SVFL and indirectly controls SVFL. The reporting person disclaims pecuniary interest in the reported securities except to the extent of his economic interest.
Remarks:
Daniel Aharon, power of attorney 09/25/2014
** 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.