SEC FORM 4 SEC Form 4
FORM 4 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

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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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
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. Issuer Name and Ticker or Trading Symbol
POTBELLY CORP [ PBPB ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director X 10% Owner
Officer (give title below) Other (specify below)
3. Date of Earliest Transaction (Month/Day/Year)
10/09/2013
4. 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 Acquired, Disposed of, or Beneficially Owned
1. Title of Security (Instr. 3) 2. Transaction Date (Month/Day/Year) 2A. Deemed Execution Date, if any (Month/Day/Year) 3. Transaction Code (Instr. 8) 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 7. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V Amount (A) or (D) Price
Common Stock 10/09/2013 C 2,586,398 A (1) 2,669,659 D(2)(3)
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 3) 2. Conversion or Exercise Price of Derivative Security 3. Transaction Date (Month/Day/Year) 3A. Deemed Execution Date, if any (Month/Day/Year) 4. Transaction Code (Instr. 8) 5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) 6. Date Exercisable and Expiration Date (Month/Day/Year) 7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4) 8. Price of Derivative Security (Instr. 5) 9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) 10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 11. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V (A) (D) Date Exercisable Expiration Date Title Amount or Number of Shares
Series E Preferred Stock (4) 10/09/2013 C 2,142,858(4) 02/13/2006 (4) Common Stock 2,217,470(4) (1) 0 D(2)(3)
Series F Preferred Stock (5) 10/09/2013 C 268,928(5) 12/24/2008 (5) Common Stock 268,928(5) (1) 0 D(2)(3)
Series F Preferred Stock (5) 10/09/2013 C 100,000(5) 01/29/2009 (5) Common Stock 100,000(5) (1) 0 D(2)(3)
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 LLC

(Last) (First) (Middle)
299 PARK AVENUE
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)
Explanation of Responses:
1. Not applicable.
2. 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.
3. 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.
4. The Series E Preferred Stock automatically converted into Potbelly Corporation ("Potbelly") common stock on a 1-to-1.0348 basis upon the closing of Potbelly's initial public offering.
5. The Series F Preferred Stock automatically converted into Potbelly 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 10/11/2013
American Securities Partners III, L.P. By: American Securities Associates III, LLC, its general partner, By: /s/ Eric Schondorf, as General Counsel 10/11/2013
American Securities Partners III(B), L.P. By: American Securities Associates III, LLC, its general partner By: /s/ Eric Schondorf, as General Counsel 10/11/2013
American Securities Associates III, LLC By: /s/ Eric Schondorf, as General Counsel 10/11/2013
American Securities LLC By: /s/ Eric Schondorf, as General Counsel 10/11/2013
** 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 4 (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).
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mm10-1113aspgrp_4e991.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):
10/9/2013
   
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):
10/9/2013
   
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):
10/9/2013
   
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):
10/9/2013
   
Designated Filer:
ASP PBSW, LLC