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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 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. | |||
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. | SEC 1474 (9-02) |
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 Underlying Securities (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 of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
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Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Brentwood-Zumiez Investors, LLC 11150 SANTA MONICA BLVD. SUITE 1200 LOS ANGELES, CA 90025 |
X | |||
BAPE III EXECUTIVE FUND L P 11150 SANTA MONICA BLVD. SUITE 1200 LOS ANGELES, CA 90025 |
Affiliate of 10% owner | |||
BRENTWOOD ASSOCIATES PRIVATE EQUITY III LP 11150 SANTA MONICA BLVD. SUITE 1200 LOS ANGELES, CA 90025 |
Affiliate of 10% owner | |||
Brentwood Associates Private Equity III-A, L.P. 11150 SANTA MONICA BLVD. SUITE 1200 LOS ANGELES, CA 90025 |
Affiliate of 10% owner | |||
Brentwood Private Equity III, LLC 11150 SANTA MONICA BLVD. SUITE 1200 LOS ANGELES, CA 90025 |
X |
William M. Barnum, Jr., authorized representative | 05/11/2005 | |
**Signature of Reporting Person | Date | |
William M. Barnum, Jr., authorized representative | 05/11/2005 | |
**Signature of Reporting Person | Date | |
William M. Barnum, Jr., authorized representative | 05/11/2005 | |
**Signature of Reporting Person | Date | |
William M. Barnum, Jr., authorized representative | 05/11/2005 | |
**Signature of Reporting Person | Date | |
William M. Barnum, Jr., authorized representative | 05/11/2005 | |
**Signature of Reporting Person | Date |
* | 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). |
(1) | Reflects securities held by Brentwood-Zumiez Investors, LLC. Brentwood Private Equity III, LLC is the general partner of Brentwood Associates Private Equity III, L.P., Brentwood Associates Private Equity III-A, L.P. and BAPE III Executive Fund, L.P., which collectively hold all of the membership interests of Brentwood-Zumiez Investors, LLC. BAPE III Executive Fund, L.P., Brentwood Associates Private Equity III, L.P. and Brentwood Associates Private Equity III-A, L.P. disclaim beneficial ownership of these securities, except to the extent of their pecuniary interest therein, and this report shall not be deemed an admission that such reporting persons are the beneficial owners of the securities for Section 16 purposes of for any other purpose. |