UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549INITIAL 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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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | SEC 1473 (7-02) | ||
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 control number. |
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 of Derivative Security: Direct (D) or Indirect (I) (Instr. 5) |
6. Nature of Indirect Beneficial Ownership (Instr. 5) |
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Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
CHS Private Equity V LP 10 SOUTH WACKER DRIVE, SUITE 3175 CHICAGO, IL 60606 |
X | |||
CHS Management V LP 10 SOUTH WACKER DRIVE, SUITE 3175 CHICAGO, IL 60606 |
X | |||
CHS Capital LLC 10 SOUTH WACKER DRIVE, SUITE 3175 CHICAGO, IL 60606 |
X |
/s/ Thomas J. Formolo, for CHS Private Equity V LP | 05/04/2011 | |
**Signature of Reporting Person | Date | |
/s/ Thomas J. Formolo, for CHS Management V LP | 05/04/2011 | |
**Signature of Reporting Person | Date | |
/s/ Thomas J. Formolo, for CHS Capital LLC | 05/04/2011 | |
**Signature of Reporting Person | Date |
* | 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). |
(1) | CHS Private Equity V LP is the record holder of these securities. CHS Capital LLC is the general partner of CHS Management V LP, which in turn is the general partner of CHS Private Equity V LP. CHS Capital LLC and CHS Management V LP disclaim beneficial ownership of the securities owned by CHS Private Equity V LP except to the extent of a pecuniary interest therein. |