FORM 3 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 INITIAL 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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1. Name and Address of Reporting Person*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 12/05/2012 |
3. Issuer Name and Ticker or Trading Symbol
IRIDEX CORP [ IRIX ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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5. If Amendment, Date of Original Filed
(Month/Day/Year) |
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6. Individual or Joint/Group Filing (Check Applicable Line)
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Table I - Non-Derivative Securities Beneficially Owned | |||
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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) |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
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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: 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 | (5) | (5) | Common Stock | 600,000 | (5) | I | BlueLine Capital Partners, LP(1) |
Series A Preferred | (5) | (5) | Common Stock | 100,000 | (5) | I | BlueLine Capital Partners II, LP(2) |
Series A Preferred | (5) | (5) | Common Stock | 300,000 | (5) | I | BlueLine Capital Partners III, LP(3) |
Explanation of Responses: |
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. |
/s/ Scott A. Shuda | 12/07/2012 | |
** 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 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). | ||
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. | ||
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 Number. |