1. Name and Address of Reporting Person * |
Â
Shuda Scott |
|
2. Date of Event Requiring Statement (Month/Day/Year) 12/05/2012 |
3. Issuer Name and Ticker or Trading Symbol IRIDEX CORP [IRIX]
|
C/O IRIDEX CORP, 1212 TERRA BELLA AVENUE |
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
__X__ Director |
__X__ 10% Owner |
_____ Officer (give title below) |
_____ Other (specify below) |
|
|
5. If Amendment, Date Original Filed(Month/Day/Year)
|
MOUNTAIN VIEW, CA 94043 |
6. Individual or Joint/Group Filing(Check Applicable Line)
_X_ Form filed by One Reporting Person
___ 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
|
1,042,970
|
I
|
BlueLine Capital Partners, LP
(1)
|
Common Stock
|
169,845
|
I
|
BlueLine Capital Partners II, LP
(2)
|
Common Stock
|
192,100
|
I
|
BlueLine Capital Partners III, LP
(3)
|
Common Stock
|
200,621
|
I
|
BlueLine Catalyst Fund IX, LP
(4)
|
|
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) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
Series A Preferred
|
Â
(5)
|
Â
(5)
|
Common Stock
|
600,000
|
$
(5)
|
I
|
BlueLine Capital Partners, LP
(1)
|
Series A Preferred
|
Â
(5)
|
Â
(5)
|
Common Stock
|
100,000
|
$
(5)
|
I
|
BlueLine Capital Partners II, LP
(2)
|
Series A Preferred
|
Â
(5)
|
Â
(5)
|
Common Stock
|
300,000
|
$
(5)
|
I
|
BlueLine Capital Partners III, LP
(3)
|
* |
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) |
The reporting person is a Managing Director of BlueLine Partners, LLC which is the General Partner of BlueLine Capital Partners, LP, the owner of the reported securities. The reporting person disclaims beneficial ownership of the reported securities except to the extent of his pecuniary interest therein. |
(2) |
The reporting person is a Managing Director of BlueLine Partners II, LLC which is the General Partner of BlueLine Capital Partners II, LP, the owner of the reported securities. The reporting person disclaims beneficial ownership of the reported securities except to the extent of his pecuniary interest therein. |
(3) |
The reporting person is a Managing Director of BlueLine Partners, LLC which is the General Partner of BlueLine Capital Partners III, LP, the owner of the reported securities. The reporting person disclaims beneficial ownership of the reported securities except to the extent of his pecuniary interest therein. |
(4) |
The reporting person is a Managing Director of BlueLine Partners, LLC which is the General Partner of BlueLine Catalyst Fund IX, LP, the owner of the reported securities. The reporting person disclaims beneficial ownership of the reported securities except to the extent of his pecuniary interest therein. |
(5) |
Each share of the issuer's Series A Preferred Stock is convertible into two shares of common stock, and has no expiration date. |