SEC FORM 3 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*
ASP PBSW, LLC

(Last) (First) (Middle)
C/O AMERICAN SECURITIES LLC
299 PARK AVE., 34TH FLOOR

(Street)
NEW YORK NY 10171

(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 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)
Form filed by One Reporting Person
X 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 83,261 D(1)(2)
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 E Preferred Stock 02/13/2006 (3) Common Stock 2,217,470(3) (3) D(1)(2)
Series F Preferred Stock 12/24/2008 (4) Common Stock 268,928(4) (4) D(1)(2)
Series F Preferred Stock 01/29/2009 (4) Common Stock 100,000(4) (4) D(1)(2)
1. Name and Address of Reporting Person*
ASP PBSW, LLC

(Last) (First) (Middle)
C/O AMERICAN SECURITIES LLC
299 PARK AVE., 34TH FLOOR

(Street)
NEW YORK NY 10171

(City) (State) (Zip)
1. Name and Address of Reporting Person*
American Securities Partners III, L.P.

(Last) (First) (Middle)
C/O AMERICAN SECURITIES LLC
299 PARK AVENUE, 34TH FLOOR

(Street)
NEW YORK NY 10171

(City) (State) (Zip)
1. Name and Address of Reporting Person*
American Securities Partners III(B), L.P.

(Last) (First) (Middle)
C/O AMERICAN SECURITIES LLC
299 PARK AVENUE, 34TH FLOOR

(Street)
NEW YORK NY 10171

(City) (State) (Zip)
1. Name and Address of Reporting Person*
American Securities Associates III, LLC

(Last) (First) (Middle)
C/O AMERICAN SECURITIES LLC
299 PARK AVENUE, 34TH FLOOR

(Street)
NEW YORK NY 10171

(City) (State) (Zip)
1. Name and Address of Reporting Person*
AMERICAN SECURITIES LLC

(Last) (First) (Middle)
299 PARK AVENUE
34TH FLOOR

(Street)
NEW YORK NY 10171

(City) (State) (Zip)
Explanation of Responses:
1. The shares are directly owned by ASP PBSW, LLC and may also be deemed to be indirectly beneficially owned by: (i) American Securities Partners III, L.P. and American Securities Partners III(B), L.P. (each, a "Sponsor"), the owners of limited liability company interests in ASP PBSW, LLC, (ii) American Securities Associates III, LLC, the general partner of each Sponsor and (iii) American Securities LLC, which provides investment advisory services to each Sponsor and is manager of ASP PBSW, LLC.
2. Each Reporting Person disclaims beneficial ownership of the reported securities except to the extent of such Reporting Person's pecuniary interest therein, and this report shall not be deemed an admission that such Reporting Person is the beneficial owner of the securities for purposes of Section 16 of the Securities Exchange Act of 1934, as amended, or for any other purpose.
3. The Series E Preferred Stock is convertible into Potbelly Corporation ("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.
4. 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.
Remarks:
See Exhibit 99.1-Joint Filer Information, incorporated herein by reference.
ASP PBSW, LLC, By: /s/ Eric Schondorf, as General Counsel 10/03/2013
American Securities Partners III, L.P. By: American Securities Associates III, LLC, its general partner, By: /s/ Eric Schondorf, as General Counsel 10/03/2013
American Securities Partners III(B), L.P. By: American Securities Associates III, LLC, its general partner By: /s/ Eric Schondorf, as General Counsel 10/03/2013
American Securities Associates III, LLC By: /s/ Eric Schondorf, as General Counsel 10/03/2013
American Securities LLC By: /s/ Eric Schondorf, as General Counsel 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.
mm10-0113aspgrp_3e991.htm

Exhibit 99.1
Joint Filer Information

Name of Joint Filer:
American Securities Partners III, L.P.
   
Address of Joint Filer:
c/o American Securities LLC
 
299 Park Ave, 34th Floor
 
New York, NY  10171
   
Relationship of Joint Filer to Issuer:
10% Owner
   
Issuer Name and Ticker or Trading Symbol:
Potbelly Corporation [PBPB]
   
Date of Event Requiring Statement:
 
(Month/Day/Year):
10/3/2013
   
Designated Filer:
ASP PBSW, LLC



Joint Filer Information

Name of Joint Filer:
American Securities Partners III(B), L.P.
   
Address of Joint Filer:
c/o American Securities LLC
 
299 Park Ave, 34th Floor
 
New York, NY  10171
   
Relationship of Joint Filer to Issuer:
10% Owner
   
Issuer Name and Ticker or Trading Symbol:
Potbelly Corporation [PBPB]
   
Date of Event Requiring Statement:
 
(Month/Day/Year):
10/3/2013
   
Designated Filer:
ASP PBSW, LLC


Joint Filer Information

Name of Joint Filer:
American Securities Associates III, LLC
   
Address of Joint Filer:
c/o American Securities LLC
 
299 Park Ave, 34th Floor
 
New York, NY  10171
 
   
Relationship of Joint Filer to Issuer:
10% Owner
   
Issuer Name and Ticker or Trading Symbol:
Potbelly Corporation [PBPB]
   
Date of Event Requiring Statement:
 
(Month/Day/Year):
10/3/2013
   
Designated Filer:
ASP PBSW, LLC

 
 
 
 
 

 
 
 

 
Joint Filer Information

Name of Joint Filer:
American Securities LLC
   
Address of Joint Filer:
299 Park Ave, 34th Floor
 
New York, NY  10171
   
Relationship of Joint Filer to Issuer:
10% Owner
   
Issuer Name and Ticker or Trading Symbol:
Potbelly Corporation [PBPB]
   
Date of Event Requiring Statement:
 
(Month/Day/Year):
10/3/2013
   
Designated Filer:
ASP PBSW, LLC