SEC FORM 3 SEC Form 3
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*
Shuda Scott

(Last) (First) (Middle)
C/O IRIDEX CORP
1212 TERRA BELLA AVENUE

(Street)
MOUNTAIN VIEW CA 94043

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
12/05/2012
3. Issuer Name and Ticker or Trading Symbol
IRIDEX CORP [ IRIX ]
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 of Original Filed (Month/Day/Year)
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)
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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.
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