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*
WI-POTBELLY LLC

(Last) (First) (Middle)
1850 SECOND STREET, SUITE 201

(Street)
HIGHLAND PARK IL 60035

(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 599,650 A (1) 672,135(2) D
Common Stock 10/09/2013 C 171,371 A (3) 843,506(2) D
Common Stock 10/09/2013 C 98,286 A (4) 941,792(2) D
Common Stock 10/09/2013 C 66,087 A (5) 1,007,879(2) D
Common Stock 10/09/2013 C 140,439 A (6) 1,148,318(2) D
Common Stock 10/09/2013 C 104,375 A (7) 1,252,693(2) D
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 A Preferred Stock $0(1) 10/09/2013 C 599,650 09/19/2001 (1) Common Stock 599,650(2) $0 0 D
Series B Preferred Stock $0(3) 10/09/2013 C 171,371 09/18/2002 (3) Common Stock 171,371(2) $0 0 D
Series C Preferred Stock $0(4) 10/09/2013 C 97,446 10/08/2003 (4) Common Stock 98,286(2) $0 0 D
Series D Preferred Stock $0(5) 10/09/2013 C 64,634 03/23/2005 (5) Common Stock 66,087(2) $0 0 D
Series E Preferred Stock $0(6) 10/09/2013 C 135,714 02/13/2006 (6) Common Stock 140,439(2) $0 0 D
Series F Preferred Stock $0(7) 10/09/2013 C 104,375 01/30/2009 (7) Common Stock 104,375(2) $0 0 D
1. Name and Address of Reporting Person*
WI-POTBELLY LLC

(Last) (First) (Middle)
1850 SECOND STREET, SUITE 201

(Street)
HIGHLAND PARK IL 60035

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

(Last) (First) (Middle)
1850 SECOND STREET, SUITE 201

(Street)
HIGHLAND PARK IL 60035

(City) (State) (Zip)
1. Name and Address of Reporting Person*
Sandburg Partners

(Last) (First) (Middle)
1850 SECOND STREET, SUITE 201

(Street)
HIGHLAND PARK IL 60035

(City) (State) (Zip)
1. Name and Address of Reporting Person*
Waveland Investments I, LLC

(Last) (First) (Middle)
1850 SECOND STREET, SUITE 201

(Street)
HIGHLAND PARK IL 60035

(City) (State) (Zip)
Explanation of Responses:
1. The Series A Preferred Stock automatically converted into Potbelly Corporation ("Potbelly") common stock on a 1-to-1 basis upon the closing of Potbelly's initial public offering and did not have an expiration date.
2. Represents shares held by WI-Potbelly, LLC. Waveland Investments I, LLC, Winchester Partners, L.P., and Sandburg Partners (collectively, the "Managing Members") are managing members of WI-Potbelly, LLC and may be deemed to beneficially own these shares. Each of the Managing Members disclaims beneficial ownership of the shares reported herein except to the extent of its pecuniary interest therein.
3. The Series B Preferred Stock automatically converted into Potbelly common stock on a 1-to-1 basis upon the closing of Potbelly's initial public offering and did not have an expiration date.
4. The Series C Preferred Stock automatically converted into Potbelly common stock on a 1-to-1.0086 basis upon the closing of Potbelly's initial public offering and did not have an expiration date.
5. The Series D Preferred Stock automatically converted into Potbelly common stock on a 1-to-1.0268 basis upon the closing of Potbelly's initial public offering and did not have an expiration date.
6. The Series E Preferred Stock automatically converted into Potbelly common stock on a 1-to-1.0348 basis upon the closing of Potbelly's initial public offering and did not have an expiration date.
7. 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 and did not have an expiration date.
/s/Dennis Zaslavsky, authorized person 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).
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