SEC Form D Altus Venture Capital Fund v 020106

8/6/2019 SEC Form D Altus Venture Capital Fund v 020106

1/9

,UNITED STATES

SECURITIES AND EXCHANGE COMMISSION OMS APPROVAL

FORM 0OMS Number: 3235-0076Expires:Estimated average burdenhours per response 16.00

W ashington, D .C. 20549

NOTICE OF SALE OF SECURITIESPURSUANT TO REGULATION D,SECTION 4(6), AND/ORUNIFORM LIMITED OFFERING EXEMPTIO 1 1 1 1 1 1 1 1 1 1 1 ~ I ~ I I ~06024804Name of Offerin~ "( I check if this is an amendment and name has changed, and indicate change.)

ALTUS VENTUR CAPITAL FUND V LLCFiling U nder (Check box(es) that apply): 0 Rule 504 0 Rule 505 0 Rule 506 0 Section 4(6)T yp e o f Filing : 0 N ew F ilin g 0 Amendment o ULOE

A. BASIC IDENTIFICATION DATAI. Enter the inform ation requested about the issuerN am e of Issuer (0 check if this is an amendment and name has changed, and indicate change.)ALTUS VENTURE CAPITAL FUND V, LLC

A ddress of Prin cip al B usin ess O peratio ns(if d ifferen t fro m E xecu tive O ffices)

(Number and Street, C ity, State, Zip Code) Telephone Number (Including Area Code)/ P R O C E S S D

F E B 2 2 2 0 0 6

A dd ress o f E xecu tiv e O ffices120W. BROADWAY, ALTUS, OK 73521 (Number and Street, C ity, State, Zip Code) Telephone Number (Including Area Code)( 58 0 ) 4 8 0- 13 2 0

B rief D escrip tion o f B usinessPASS THROUGH VENTURE CAPITAL ENTITYT yp e o f B usi ne ss O rg an iz atio no corporationo b us in es s t ru st o lim ited p artne rsh ip, alread y fo rm edo lim ited p artn ersh ip , to b e form ed lZ l o th er ( ple ase sp ec if y) :limited liability company

Month YearA ctu al o r E stim ated D ate o f In co rp oratio n o r O rg an izatio n: I T I : Q J r o : : : : E J 1 2 1 Actual 0 EstimatedJurisdiction of Incorporation or O rganization: (Enter tw o-letter U .S . Postal Service abbreviation for State:

C N fo r C an ad a; FN f or o th er f or ei gn j ur is di ct io n) C C l r nGENERAL INSTRUCTIONSFederal:Who Must File: A ll issu ers m aking an o ffering o f secu rities in re lian ce o n an ex em ptio n u nd er R eg ulatio n D o r S e ct io n 4(6), J 7 CF R 230,501 et seq . or 15 U,S,c.77d(6).When To File: A notice must be filed no later than 1 5 days after the first sale of securities in the offering, A notice is deemed filed with the U,S, Securitiesand Exchange Commission (SEC) on the earlier of the date it is received by the SEC at the address given below or, if received at that address after the date onwhich it is due, on the date it was m ai le d by U nited States registered or certified m ail to that address,Where To File. U S. Se curities a nd E xch ang e C om missio n, 450 Fifth Street, N .W ., W ashington, D .C. 20549.Copies Required: Five IS) copies of this notice must be filed with the SEC, one of which must be manually signed. Any copies not manually signed must bephotocopies of the m anually signed copy or bear typed or printed signatures.Information Required: A new filing must contain all information requested. Amendments need only report the name of the issuer and offering, any changesthereto, the inform ation requested in Part C , and any m aterial changes from the inform ation previously supplied in Parts A and B. Part E and the A ppendix neednot be filed w ith the SEC.F ilin g F ee : There is no federal filing fee,State:This notice shall be used to indicate reliance on the U niform Lim ited O ffering Exemption (ULO E) for sales of securities in those states that have adoptedULOE and that have adopted this form . Issuers relying on ULOE must file a separate notice w ith the Securities Administrator in each state where salesare to be, or have been made. Ifa state requires the payment of a fee as a precondition to the claim for the exemption, a fee in the proper amount shallaccompany this form , This notice shall be filed in the appropriate states in accordance w ith state law . The Appendix to the notice constitutes a part ofthis notice and m ust be com pleted,~------------------------------AnENTION------------------------------~

F ailure to file notice in the appropria te sta tes will not resu lt in a loss of the federa l exem ption. C onverse ly , fa ilu re to file theapp ropria te federa l notice w ill no t resu lt in a loss 0 1 an availab le sta te exem ption unless su ch exem ption is pred ic ta ted on thefilin g o f a fe de ra l n otic e.

SEC 1972 (6-02)Persons who respond to the collection of information contained in this form are notrequired to respond unless the form displays a currently valid OMB control number. I of 9


2/9

,A. BASIC IDENTIFICATION DATA

2. Enter the inform ation requested for the follow ing: Each promoter of the issuer. if the issuer has been organized within the past five years; Each beneficial owner having the power to vote or dispose. or direct the vote or disposition of. 10% or more of a class of equity securities of the issuer. Each executive officer and director of corporate issuers and of corporate general and m anaging partners of partnership issuers; and Each general and managing partner of partnership issuers.

C heck B ox(es) that A pply: o Promoter o B en ef ic ia l O wn er 0 E xe cu ti ve O ff ic er 0 Director IZ I Gen er al a nd /o rM an ag in g P ar tn er

Full N am e (L ast nam e first, if individual)OKLAHOMA INDUSTRIAL VENTURE MANAGEMENT COMPANY, LLCBusiness or Residence Address (Number and Street, C ity , Stale, Zip Code)120 W, BROADWAY, ALTUS, OK 73521C heck B ox(es) that A pply: o Promoter ~ Beneficial Owner 0 E xe cu ti ve O ff ic er 0 Director o Gen er al a nd /o r

M an ag in g P ar tn erFull N am e (L ast nam e first, if individual)FSB BANCORP, INC.Business or Residence Address (Number and Street, C ity , State, Zip Code)721 N. MAIN STREET, P.O. BOX 979, ALTUS, OK 73522-0979C heck B ox(es) that A pply: o Promoter III B en ef ic ia l O wn er 0 E xe cu ti ve O ff ic er 0 Director o Gen er al a nd /o r

M an ag in g P ar tn erFull N am e (L ast nam e first, if individual)CFO MANAGEMENT, LLCBusiness or Residence Address (Number and Street, C ity , State, Zip Code)120 W. BROADWAY, ALTUS, OK 73521C heck B ox(es) that A pply: o Promoter o B en ef ic ia l O wn er 0 E xe cu ti ve O ff ic er 0 Director o Gen er al a nd /o r

M an ag in g P ar tn erFull N am e (L ast nam e first, if individual)PAUL H. DOUGHTYBusiness or Residence Address (Number and Street, C ity , State, Zip Code)721 N. MAIN STREET, P.O. BOX 979, ALTUS, OK 73522-0979C heck 8ox(es) that A pply: o Promoter o B en ef ic ia l O wn er 0 E xe cu ti ve O ff ic er 0 Director o G en era l a nd /o r

M an ag in g P ar tn erFull N am e (L ast nam e first, if individual)F. DON ANDERSONBusiness or Residence Address (Number and Street, C ity , State, Zip Code)120 W. BROADWAY, ALTUS, OK 73521C heck B ox( es) that A pply: o Promoter o B en ef ic ia l O wn er III E xe cu ti ve O ff ic er 0 Director o G en era l a nd /o r

M an ag in g P ar tn er

Full N am e (L ast nam e first, if individual)WILLIAM R. GRISSOMBusiness or Residence Address (Number and Street, C ity , State, Zip Code)120 W. BROADWAY, ALTUS, OK 73521C heck B ox(es) that A pply: o Promoter o B en ef ic ia l O wn er iii E xe cu ti ve O ff ic er 0 Director o Gen er al a nd /o r

M an ag in g P ar tn erFull N am e (L ast nam e first, if individual)SIDNEY S. FARRBusiness or Residence Address (Number and Street, C ity , State, Z ip Code)6500 N.W. GRAND DRIVE, OKLAHOMA CITY, OK 73116

(Use blank sheet, or copy and use additional copies of this sheet, as necessary)20f9


3/9

. . .B. INFORMATION ABOUT OFFERING

Yes NoI. Has the issuer sold, or does the issuer intend to sell, to non-accredited investors in this offering? ..

Answer also in Appendix, Column 2, if filing under ULOE.r

2. What is the minimum investment that will be accepted from any individual? . $ 500,000.00Yes No

3. Does the offering permit joint ownership of a single unit? [ij [J4. Enter the information requested for each person who has been or will be paid or given, directly or indirectly, any

com mission or sim ilar rem uneration for solicitation of purchasers in connection w ith sales of securities in the offering.If a person to be I isted is an associated person or agent of a broker or dealer registered with the SEC andlor with a stateor states, list the name of the broker or dealer. Ifmore than five (5) persons to be listed are associated persons of sucha broker or dealer, you may set forth the information for that broker or dealer only.

Full Name (Last name first, if individual)CAPITAL WEST SECURITIES, INC.Business or Residence Address (Number and Street, C ity, State. Zip Code)211 NORTH ROBINSON, SUITE 200, OKLAHOMA CITY, OK 73102Name of Associated Broker or Dealer

States in Which Person Listed Has Solicited or Intends to Solicit Purchasers(Check "All States" or check individual States) 0 A ll S ta te sIALI IAKI IAZI IARI ICAI Icol ICTI 10EI loci IFLI IGAI o m o m01J Dill [ITJ IKSI IKYI ILAI IMEI IMOI IMAI [MI] IMNI IMSI IMOIIMTI INEI INVI INHI lliIJ INMI INYI INCI INOI 10H I lelKl 10RI IPAIDill [gJ Isol ITNI ITXI IUTI IVTI IVAI IWAI Iwvl IWII Iwyl IPRI

Full Name (Last name first, if individual)

Business or Residence Address (Number and Street, City, State, Zip Code)

Name of Associated Broker or DealerStates in W hich Person Listed Has Solicited or Intends to Solicit Purchasers

(Check "All States" or check individual States) ... ,......,... .......,.. ....... ,. . . . ... . . . . . . . . ........ . . . . . ... . .,.. ... ..... . . . . ................ o A ll S ta te sIALI IAKI IAZI IARI ICAI Icol lerl 10EI loci IFLI IGAI o m [ill][KI o m QAJ IKsl IKYI ILAI IMEI IMOI IMAI I MIl IMNI IMSI IMOIIMTI INEI INVI INHI lliIJ INMI INyl INCI INol IOH I lOKI 10RI IPAI[ill Isci Isol ITNI ITX I IUTI IVTI IVAI IWAI Iwvl IWII IWyl IPRI

Full Name (Last name first, if individual)

Business or Residence Address (Number and Street, City, State, Zip Code)

Name of Associated Broker or Dealer

States in Which Person Listed Has Solicited or Intends to Solicit Purchasers(Check "All States" or check individual States) ,.......,......... ....................... . . . ..... . . . . . . . . .. o A ll S tat esIALI IAKI IAzl IARI ICAI Icol ICTI 10EI loci [1J IGAI o m []I][KI o m QAJ IKsl IKyl ILAI IMEI IMOI 1MAI IMII IMNI IMSI IMOIIMTI INEI INVI INHI IN] I INMI INyl INCI INOI IOHI lOKI 10RI IPAIDill Isci Isol ITNI ITXI IUTI IVTI IVAI IWAI Iwvl IWII IWyl IPRI

(U se blank sheet, or copy and use additional copies of this sheet, as necessary.)30f9


4/9

C. OFFERING PRICE, NUMBER OF INVESTORS, EXPENSES AND USE OF PROCEEDS

1. Enter the aggregate offering price of securities included in this offering and the total am ount alreadysold. E nter ;


5/9

C. OFFERING PRICE, NUMB.ER OF INVESTORS, EXPENSES AND USE OF PROCEEDS

b. Enter the difference between the aggregate offering price given in response to Part C - Q uestion Iand total expen ses furnishe d in response to P art C - Q uestion 4.a. T his diffe rence is the "ad justed grossproceeds to the issuer." .

5. Indicate below the amount of the adjusted gross proceed to the issuer used or proposed to be used foreach of the purposes shown. If the amount for any purpose is not known, furnish an estimate andcheck the box to the left of the estim ate. The tota l of the paym ents listed m ust equal the adjusted grossproceeds to the issuer set forth in response to Part C - Q uestion 4 .b above.

P aym ents toOfficers,

Directors, &Affiliates

S al arie s and fees G 2 l $ 41,666.73Purchase of real estate " 0$ _P urchase, rental or lea sing and installation of m achineryand equipment "'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 0$ _C onstruction or leasing of plant buildings a nd facilities 0$ _A cquisition of other businesses (including the value of securities involved in thisoffering that may be used in exchange for the assets or securities of anotherissuer pursuant to a m erger) 0$ _R ep ay me nt o f in de bte dn es s 0$ _Wo rk in g c ap ita l 0$ _O ther (specify): V EN TU RE C APIT AL IN VESTM EN TS 0$ __R_E_S_E_R_V_E O $ _C olu mn T ota ls I I I $ 41,666.73

$ 1,935,454.59

Paym ents toOthers0$.0 00$ _

0$----0$----0$OS0$~$ 1,607,872.29

OS 285,915.57IZJ$ 1,893,787.86

Total Paym ents Listed ( co lumn totals added) . ~ s 1,935,454.59D. FEDERAL SIGNATURE

The issuer has duly caused this notice to be signed by the undersigned duly authorized person. Ifth is notice is fil e d under R ule 505, the follow ingsignature constitutes an undertaking by the issuer to furnish to the U .S. Securities and Exchange C om mission, upon w ritten request of its staff,the information furnished by the issuer to any non-accredited investor pursuant to para (b)(2) of Rule 502.Issuer (P rint or T ype)ALTUS VENTURE CAPITAL FUND V , LLC

Date ;2-/-0(,Nam e of S igner (Print or Type)Paul H . D oughty

Title of Signer (Print or Type)President, A ltus V enture Capital Fund V , LLC

.---------------- ATTENTIONIntentional misstatements or omissions of fact constitute federal criminal violations. (See 18 U.S.C. 1001.)

50f9


6/9

I

E; STATE SIGNATUREI. Is any party described in 17 CFR 230.262 presently subject to any of the disqual ification YesID NoI & lrovisions of such rule? ..

See A ppendix, Column 5, for state response.2. The undersigned issuer hereby undertakes to furnish to any state administrator of any state in which this notice is filed a notice on FormD (17 CFR 239.500) at such times as required by state law.3 . The undersigned issuer hereby undertakes to furnish to the state adm inistrators, upon written request, information furnished by the

is su er to o ff erc es .4. The undersigned issuer represents that the issuer is fam iliar with the conditions that must be satisfied to be entitled to the Uniform

lim ited O ffering Exem ption (ULOE) of the state in which this notice is filed and understands that the issuer claim ing the availabilityof this exemption has the burden of establishing that these conditions have been satisfied.

The issuer has read this notification and knows the contents to be true and has duly caused this notice to be signed on its behalf by the undersigneddu ly au tho riz ed pe rson .Issuer (P rint or T ype)ALTUS VENTURE CAPITAL FUND V, LLC

Date

:2-I-tJt,Name (Print or Type)Paul H. Doughty President, Altus Venture Capital Fund V, LLC

Instruction:Print the name and title of the signing representative under his signature for the state portion of this form. One copy of every notice on FormD must be manually signed. Any copies not manually signed must be photocopies of the manually signed copy or bear typed or printedsignatures.

60f9


7/9

I . .APPENDIX

1 2 3 4 5Disqualification

Type of security under State ULOEIntend to sell and aggregate (if yes, attach

to non-accredited offering price Type of investor and explanation ofinvestors in State offered in state amount purchased in State waiver granted)(Part B-ltem I) (Part C-Item 1) (Part C-Item 2) (Part E-Ttem I)

Number of Number ofAccredited Non-Accredited

State Yes No Investors Amount Investors Amount Yes NoAL L _ _ _ . .C..... _ ........ ..'AK nCCZ 1 , _ _ .. . . . . . . . 'AR ! C-" ..~... ~,CA ~ C.._- -co L CA_"~~,, ...CT I I..,.~~~-- .. .--. ..,-"......;DE . . . J t., ... I_ __ ._ _~>m~DC I : I I ie..FL L ,_< 1 . . . .. . . .. . . ,.....................GA L . . . . _ . . 1 . . . . . , ' " . . [HI I I CL , , = !ID I I L . ._ . . . . r=='-.. =..;":"IL ! C. . . . . . . . . .T N L [_.., .. ;...... ,. . . . . . ,-,-IA , L . . ._ . _ L _ . . _ ... .KS I I L . . _ . . . . . . . . . . DCi tY I I I.. _ . .._ ........... _ ..,LA C :..... . - ...ME t ; DC,'"~~~'''"'~~'-'~MD L~_~._. jMA I ' ' _ . , . 1_ ................ !.MI I I C~" .. -MN I I L . . . . . . . . , , ~ I IMS 1 _ _ . , . _ : I I C

70f9


8/9

,APPENDIX

2

In te nd to s ellto non-acc red itedi nv es to rs i n S ta te(Pa rt B - It em I)

3Typ e o f s ec ur it yand aggr eg at eo ff er in g p ri ceoffered in state( pa rt C -I tem 1)

Number ofAccreditedInvestors

4

Type of investor andam ou nt pu rch ased in S tate(Pa rt C - It em 2)

AmountNumber of

Non-Accredited

5Disqualificationun der S tate U LOE(if ye s, a tt ache xp la na tio n o fwa iv er g rant ed )(Pa rt E -I tem I)

State Yes NoMO I ! IMTNE L , _ " " " JNV I

- .....__J

Investors Amount Yes No

I L _ _ .

NH I INJNM I INYNC

OR

I " - _ _ __ _

L r-.I _ . \ I .I

1 _ . . . . I iPA r--RISCSD ITN II 1 _ _ - ' "I . .TX IUT - - ,VT IVA I

~II ; L

CI , tL IL 1 . . . . , _

wy I I

8of9


9/9

)

APPENDIX1 2 3 4 5

DisqualificationType of security under State ULOE

Intend to sell and aggregate (if yes, attachto non-accredited offering price Type of investor and explanation ofinvestors in State offered in state amount purchased in State waiver granted)(Part B-Item 1) (Part C-Item I) (Part C-Item 2) (Part E-Item \)

Number of Number ofAccredited Non-Accredited

State Yes No Investors Amount Investors Amount Yes No

WY I I I I r--PR I L ___ " , L " , , _ I I~~.-, - __ _o,_

90f9

Documents

SEC Form D Altus Venture Capital Fund v 020106