0001144204-14-074340.txt : 20141216 0001144204-14-074340.hdr.sgml : 20141216 20141216200054 ACCESSION NUMBER: 0001144204-14-074340 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20141212 FILED AS OF DATE: 20141216 DATE AS OF CHANGE: 20141216 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: POTBELLY CORP CENTRAL INDEX KEY: 0001195734 STANDARD INDUSTRIAL CLASSIFICATION: RETAIL-EATING PLACES [5812] IRS NUMBER: 364466837 FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 222 MERCHANDISE MART PLAZA STREET 2: 23RD FLOOR CITY: CHICAGO STATE: IL ZIP: 60654 BUSINESS PHONE: 3129510600 MAIL ADDRESS: STREET 1: 222 MERCHANDISE MART PLAZA STREET 2: 23RD FLOOR CITY: CHICAGO STATE: IL ZIP: 60654 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Maveron General Partner III LLC CENTRAL INDEX KEY: 0001587645 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-36104 FILM NUMBER: 141290997 BUSINESS ADDRESS: STREET 1: 411 1ST AVENUE SOUTH, SUITE 600 CITY: SEATTLE STATE: WA ZIP: 98104 BUSINESS PHONE: (206)288-1700 MAIL ADDRESS: STREET 1: 411 1ST AVENUE SOUTH, SUITE 600 CITY: SEATTLE STATE: WA ZIP: 98104 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Maveron LLC CENTRAL INDEX KEY: 0001587953 STATE OF INCORPORATION: WA FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-36104 FILM NUMBER: 141290999 BUSINESS ADDRESS: STREET 1: 411 1ST AVENUE SOUTH, SUITE 600 CITY: SEATTLE STATE: WA ZIP: 98104 BUSINESS PHONE: (206)288-1700 MAIL ADDRESS: STREET 1: 411 1ST AVENUE SOUTH, SUITE 600 CITY: SEATTLE STATE: WA ZIP: 98104 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Maveron Equity Partners III, L.P. CENTRAL INDEX KEY: 0001587648 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-36104 FILM NUMBER: 141291002 BUSINESS ADDRESS: STREET 1: 411 1ST AVENUE SOUTH, SUITE 600 CITY: SEATTLE STATE: WA ZIP: 98104 BUSINESS PHONE: (206)288-1700 MAIL ADDRESS: STREET 1: 411 1ST AVENUE SOUTH, SUITE 600 CITY: SEATTLE STATE: WA ZIP: 98104 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: MEP 2000 Associates LLC CENTRAL INDEX KEY: 0001587781 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-36104 FILM NUMBER: 141291003 BUSINESS ADDRESS: STREET 1: 411 1ST AVENUE SOUTH CITY: SEATTLE STATE: WA ZIP: 98104 BUSINESS PHONE: (206)288-1700 MAIL ADDRESS: STREET 1: 411 1ST AVENUE SOUTH CITY: SEATTLE STATE: WA ZIP: 98104 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Maveron Equity Partners 2000, L.P. CENTRAL INDEX KEY: 0001391085 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-36104 FILM NUMBER: 141291005 BUSINESS ADDRESS: STREET 1: 505 FIFTH AVENUE SOUTH STREET 2: SUITE 600 CITY: SEATTLE STATE: WA ZIP: 98104 BUSINESS PHONE: 206.288.1714 MAIL ADDRESS: STREET 1: 505 FIFTH AVENUE SOUTH STREET 2: SUITE 600 CITY: SEATTLE STATE: WA ZIP: 98104 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: MEP Associates III, L.P. CENTRAL INDEX KEY: 0001587647 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-36104 FILM NUMBER: 141290998 BUSINESS ADDRESS: STREET 1: 411 1ST AVENUE SOUTH, SUITE 600 CITY: SEATTLE STATE: WA ZIP: 98104 BUSINESS PHONE: (206)288-1700 MAIL ADDRESS: STREET 1: 411 1ST AVENUE SOUTH, SUITE 600 CITY: SEATTLE STATE: WA ZIP: 98104 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Maveron Equity Partners 2000-B, L.P. CENTRAL INDEX KEY: 0001587782 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-36104 FILM NUMBER: 141291004 BUSINESS ADDRESS: STREET 1: 411 1ST AVENUE SOUTH CITY: SEATTLE STATE: WA ZIP: 98104 BUSINESS PHONE: (206)288-1700 MAIL ADDRESS: STREET 1: 411 1ST AVENUE SOUTH CITY: SEATTLE STATE: WA ZIP: 98104 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Maveron General Partner 2000 LLC CENTRAL INDEX KEY: 0001587783 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-36104 FILM NUMBER: 141291000 BUSINESS ADDRESS: STREET 1: 411 1ST AVENUE SOUTH CITY: SEATTLE STATE: WA ZIP: 98104 BUSINESS PHONE: (206)288-1700 MAIL ADDRESS: STREET 1: 411 1ST AVENUE SOUTH CITY: SEATTLE STATE: WA ZIP: 98104 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Maveron III Entrepreneurs Fund, L.P. CENTRAL INDEX KEY: 0001587646 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-36104 FILM NUMBER: 141291001 BUSINESS ADDRESS: STREET 1: 411 1ST AVENUE SOUTH, SUITE 600 CITY: SEATTLE STATE: WA ZIP: 98104 BUSINESS PHONE: (206)288-1700 MAIL ADDRESS: STREET 1: 411 1ST AVENUE SOUTH, SUITE 600 CITY: SEATTLE STATE: WA ZIP: 98104 4 1 v396777_4.xml OWNERSHIP DOCUMENT X0306 4 2014-12-12 0 0001195734 POTBELLY CORP PBPB 0001391085 Maveron Equity Partners 2000, L.P. 411 FIRST AVENUE SOUTH, SUITE 600 SEATTLE WA 98104 0 0 1 0 0001587782 Maveron Equity Partners 2000-B, L.P. 411 FIRST AVENUE SOUTH, SUITE 600 SEATTLE WA 98104 0 0 1 0 0001587781 MEP 2000 Associates LLC 411 FIRST AVENUE SOUTH, SUITE 600 SEATTLE WA 98104 0 0 1 0 0001587648 Maveron Equity Partners III, L.P. 411 FIRST AVENUE SOUTH, SUITE 600 SEATTLE WA 98104 0 0 1 0 0001587646 Maveron III Entrepreneurs Fund, L.P. 411 FIRST AVENUE SOUTH, SUITE 600 SEATTLE WA 98104 0 0 1 0 0001587783 Maveron General Partner 2000 LLC 411 FIRST AVENUE SOUTH, SUITE 600 SEATTLE WA 98104 0 0 1 0 0001587953 Maveron LLC 411 FIRST AVENUE SOUTH, SUITE 600 SEATTLE WA 98104 0 0 1 0 0001587647 MEP Associates III, L.P. 411 FIRST AVENUE SOUTH, SUITE 600 SEATTLE WA 98104 0 0 1 0 0001587645 Maveron General Partner III LLC 411 FIRST AVENUE SOUTH, SUITE 600 SEATTLE WA 98104 0 0 1 0 Common Stock 2014-12-12 4 J 0 1000000 0 D 3310931 D Common Stock 2014-12-12 4 J 0 6809 0 A 6809 D Common Stock 2014-12-12 4 J 0 6809 0 D 0 D Common Stock 2014-12-12 4 J 0 2442 0 A 2442 D Common Stock 2014-12-12 4 J 0 2442 0 D 0 D Common Stock 2014-12-12 4 J 0 8713 0 A 11271 D Common Stock 2014-12-12 4 J 0 8593 0 D 2678 D Maveron 2000, Maveron 2000-B, MEP 2000, MEP III, Maveron-Entrepreneurs' and MEP-Associates made pro rata distributions for no consideration of 1,000,000 shares of common stock of the issuer to their partners on December 12, 2014 (the "Distribution"). Includes shares held by Maveron Equity Partners 2000, L.P. ("Maveron 2000"), Maveron Equity Partners 2000-B, L.P. ("Maveron 2000-B"), MEP 2000 Associates LLC ("MEP 2000"), Maveron Equity Partners III, L.P. ("MEP III"), Maveron III Entrepreneurs' Fund, L.P. ("Maveron-Entrepreneurs'") and MEP Associates III, L.P. ("Maveron-Associates"). Maveron General Partner 2000 LLC ("Maveron GP"), as the general partner of each of Maveron 2000 and Maveron 2000-B, may be deemed to beneficially own certain of these shares. Maveron LLC, as the manager of MEP 2000, may be deemed to beneficially own certain of these shares. Maveron General Partner III LLC ("Maveron GP III"), as the general partner of each of MEP III, Maveron-Entrepreneurs' and Maveron-Associates, may be deemed to beneficially own certain of these shares. Shares acquired by Maveron GP in connection with the Distribution of such shares to the partners of Maveron 2000 and Maveron 2000-B. Shares are owned directly by Maveron GP. Maveron GP made pro rata distributions for no consideration of 6,809 shares of common stock of the issuer to its members on December 12, 2014. Shares acquired by Maveron GP III in connection with the Distribution of such shares to the partners of MEP III, Maveron-Entrepreneurs' and Maveron-Associates. Shares are owned directly by Maveron GP III. Maveron GP III made pro rata distributions for no consideration of 2,442 shares of common stock of the issuer to its members on December 12, 2014. Shares acquired by Maveron LLC in connection with the Distribution of such shares to the partners of MEP 2000 and Maveron-Associates. Shares are owned directly by Maveron LLC. Maveron LLC made pro rata distributions for no consideration of 8,593 shares of common stock of the issuer to its members on December 12, 2014. Each reporting person disclaims the existence of a "group" and disclaims beneficial ownership of any securities except to the extent of such reporting persons' pecuniary interest in such securities. /s/ Pete McCormick, as managing member of the GP of Maveron Equity Partners 2000, L.P. 2014-12-15 /s/ Pete McCormick, as managing member of the GP of Maveron Equity Partners 2000-B, L.P. 2014-12-15 /s/ Pete McCormick, as managing member of the manager of MEP 2000 Associates LLC 2014-12-15 /s/ Pete McCormick, as managing member of the GP of Maveron Equity Partners III, L.P. 2014-12-15 /s/ Pete McCormick, as managing member of the GP of Maveron III Entrepreneurs' Fund, L.P. 2014-12-15 /s/ Pete McCormick, as managing member of Maveron General Partner 2000, LLC 2014-12-15 /s/ Pete McCormick, as managing member of Maveron, LLC 2014-12-15 /s/ Pete McCormick, as managing member of the GP of MEP Associates III, L.P. 2014-12-15 /s/ Pete McCormick, as managing member of Maveron General Partner III LLC 2014-12-15