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