SEC Form D Affinity Ventures Capital Fund I SB-5

8/6/2019 SEC Form D Affinity Ventures Capital Fund I SB-5

http://slidepdf.com/reader/full/sec-form-d-affinity-ventures-capital-fund-i-sb-5 1/9

FORM DU NIT E~ S TA TE S

SE CtJR IT IE S A ND E XC HA NG E C OM MISSIO N

W ash in gto n, D .C . 2 11 54 9

D ~ J 3 { o 1OMB APPROVAL

OMS Number: 3235-0076

Expires: May 31,2005

Estimated average burden

hours per response 16.00ORM D

NOTICE OF SALE OF SECURITIES

PURSUANT TO REGULATION D,

SECTION 4(6), AND/OR

UNIFORM LIMITED OFFERING EXEMPTION

SEC USE ONLYPrefix

I ISerial

D A TE R EC E IV E D

I I

A . BA SIC ID EN TIFICA TIO N D ATA

. '.: N _~ m e? ~ O ff er in g to c he ck if th is is a n a me nd me nt a nd n am e h as c ha ng ed , a nd in dic ate c ha ng e.)

. AFFINITY VENTURES CAPITAL FUND I, LLC, CLASS SB-5 COMMON UNITS

F ilin g U n de r ( Ch ec k b ox tc s) th at a pp ly ): 0 Rule 504 0 Rule 505 0 R ule 5 06 0 Sect ion 4 (6)

Type o f F i! in g: ' 0 New F il in g 0 Amendment, - v - . • r

I. . E nte r th e in fo rm atio n re qu este d a bo ut th e issu er

Name of Issuer (0c he ck if th is is a n a me nd me nt a nd n am e h as c ha ng ed , a nd in dic ate c ha ng e.)

AFFINITY VENTURES CAPITAL FUND I, LLC

Addr es s o f P ri nc ip al B u si ne ss Op er at io ns( if d if fe re n t f rom Ex ecut iv e O f fi ce s)

( Nu mb er a nd S tr ee t, C ity . S ta te , Z ip C od e) T ele ph on e N u mb er ( In clu di ng A re a C od e),

Address of E xecutiveO ffices (Number and Street, C ity. State, Zip C ode)

211 NORTH ROBINSON, SUITE 210, OKLAHOMA CITY, OK 73102

Te le ph on e N ilmbe r' (l nc lu dr ng A r ea C ode )

405-235-5700' ,~/

Type o f B u si ne ss O r gani za ti on

o corporation',

o busi n es s t ru s t

o l im i te d p ar tn er sh ip , a lr ea dy f orm ed

o lim ite d p ar tn er sh ip , to b e f or me d

o o the r (p lease spec ify );

; l im i ted l iab il l1 v . .nnl'An

B r ie f De sc ri pt io n o f B u si ne ssJ,

PASS THROUGH VENTURE CAPITAL ENTITY

M onth Year

A ctu al o r E st im ate d p ate o f I nc or po ra tio n o r O rg an iz atio n:. [{[[9] ~ I2 lActual 0 Estimated

J ur is dic ti on o f I nc or po ra ti on o r O rg an iz ati on ; ( En te r tw o- le tte r U .S . P os ta l S er vic e a bb re via tio n f or S ta te :

: CN for Canada: FN for other foreign jurisdiction) I!l[]

G E NE RA L I NS TR U CT IO N S

Federal: '_. .

Who Must File; A ll i §s ue rs ma ki ng a n o ff er in g o f's ec ur itie s in r elia nc e o n a n e xemp tio n u nd er R eg ula tio n D o r S ec tio n 4 (6 ), J 7 C FR 2 30 .5 01 e t s e q. o r 1 5 U .S .c .77d(6). ";.., : :~.~ I

Whell To File: A not ic e must-be 'file d ' no la te r th an 1 5 d ay s a fte r th e first sa le o f se cu ritie s in th e o ffe rin g. A n otic e is d ee me d file d w ith th e U .S . S ec uritie s

a nd E xc ha ng e C om m issiO l; (S EC ) o n th e e arlie r o f th e d ate it is re ce iv ed b y th e S EC a t th e a dd re ss g iv en b elo w o r, if re ce iv ed a t th at a dd re ss a fte r th e d ate o n

w hic h it is d ue , o n th e d ate it-w as m aile d b y U nite d S ta te s re giste re d o r c ertifie d m ail to th at a dd re ss.

Where To File: U .~ ;' S e~ Ur iti~ S a nd E xc ha ng e C om m is sio n, 4 50 F if th S tr ee t. N .W ., W a sh in gto n, D .C . 2 05 49 .

Copies Required: Fjye (5) c op ie s o f th is n otic e m ust b e f ile d w ith th e S EC , o ne o f w hic h m ust b e m an ua lly s ig ne d. A ny c lo pie s n ot m an ua lly s ig ne d m ust b e

p ho to co pie s o f th e m an ua lly '~ ig ne d c op y o r b ea r ty pe d o r p rin te d s ig na tu re s.~ ~ . . , ' : . . ' . 1

Information Required: A n ew filin g l_ O!lst o nta in a ll in fo rm atio n re qu este d. A m en dm en ts n ee d o nly re po rt th e n am e o f th e issu er a nd o ffe rin g, a ny c ha ng es

th er eto , t he in fo rm a iio n r eq ue ste d in P ar t C . a nd a ny m ate ria l c ha ng es f ro m th e in fo rm atio n p re vio us ly s up plie d in P ar ts A a nd B . P ar t E a nd th e A pp en dix n ee d

not be filed w ith thC:SEC. '..:

Filmg Fee: T he re is n o f ed er al f il ;:n g f ee ." .

State: .

T his n otic e s ha ll b e, \ls ed to in dic ate r elia nc e 011 th e U nifo rm L im ite d O ffe rin g E xe mp tio n (U LO E) fo r sa le s o f se cu ritie s in th ose sta te s th at h av e a do pte d

U LO E and that have adopte d this form . Issuers relyin g on lJL OE m ust tile a separate n otice w ith the Securities A dm inistrator in each state w here sales

are to be, or have b~en m ade. If a state requires the paym ent of a fee as a precondition to the claim for the exem ption, a fce in the proper am ount shall

accom pan y this fon n . T his no tice shall be filed in the appropriate states in ac cordance w ith state law . T he A ppend ix' to the notice constitutes a p art of

th is n otic e a nd m u s,t b e c om ple te d.

" ATENTON--------:---------,

F ailu re to 1ile no tice in the approp ria te states w ill not resu lt in a loss 01 the lederal exem ption. C onverse ly, failure to file the

a pp ro pria te fed eral n otic e w ill no t re sult in a loss 01 a n a vaila ble sta te exe mp tion un less suc h ex em ptio n is p re dicta te d o n th e

filin g 0 1 a 'e de :ra l n otic e.

,!,

SEC 1972 (6-02)Persons who respond to the collection of information contained in this form ar'e notrequired to respond unless the form displays a curren lly valid OMS control number. 10f9



2. Enter the infomi~lion requested for the following:

• Each promoter of the issuer, if the issuer ha~ b~e~.o~~anized 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 secur ities of the issuer .

i• Each executive officer and director of corpor~te issuers and of corporate general and managing partners of partnership issuers; and

• Each general and managing partner of partnership issuers.

Check Box(cs) that Apply: e I .General and/orManaging Partnero

Promoter

oBeneficial Owner

0Executive Officer

0Director

Full Name (Last name. first, if individual)

AFFINITY VENTURES, lLC

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

211 NORTH ROB[NSON, SUITE 210, OKLAHOMA CITY, OK 73102

Check Rox(es) that A'pply: III Beneficial Owner 0 Executive Officer 0 Director o I General andlor, Managing Partner

o Promoter

Ful l Name (Last name first , if individual)

BENEVOLENT HOLDINGS CORPORATION



Check Box(es) that Apply: o Promoter o i General andlor

Managing Partner

o Beneficial Owner ~ Executive Officer 0 Director

Full Name (Last nam~ first , i f individual)

MCDONALD, ROBERT 0,


211 NORTH ROBI",SON, SUITE 210, OKLAHOMA CITY, OK 73102

Check Box(es) that Apply:,<

o Beneficial Owner 0 Executive Officer 0 Director 0 : General.and/orI Managtng Partner

o Promoter

Ful l Name (Last name first , if individual),<

RADER, ROBERT!G,"


211 NORTH ROB:INSON, SUITE 210, OKLAHOMA CITY, OK 73102

Check Box(es) that Apply: o· Beneficial Owner 0 Executive Officer 0 Director o IGeneral and/orManaging Partner

o Promoter

Ful l Name (Las! name first , if individual)

HARGIS, JERRI 't .


211 NORTH ROB!,NSON, SUITE 210, OKLAHOMA CITY, OK 73102

Check Box( es) that Apply: o Beneficial Owner 0 Executive Officer 0 Director D·General andlorManaging Partner

o Promoter

Full Name (Last name first, if individual)


Check Box(es) that Apply: o i General and/orI Managi ng Partner

o Promoter o Beneficial Owner 0 Executive Officer 0 Director

Full Name (Last name first, if individual)

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

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

20f9



Yes No

0 ~

S10,000.00

Yes No

I ! I !d

I. 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 undcr ULOE.I

2. What is the minimum investment that will be accepted from any individual? .

"3. Does the offeri~g permit joint ownership of a single unit? ...4. 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 with sales of securities in the loffering.

If a person to b~ listed is an associated person or agent of a broker or dealer registered with the SEC and/or with IIstate

or states. list the name of the broker or dealer. If'more than five (5) persons to be: l isted are associated person's of such

a broker or dealer, you may set forth the information for that broker or dealer only._l."

Full N am e (Last nam e first. if individual)

CAPITAL WEST ~ECURITIES, INC.



Name of Associated Broker or Dealer

. ~

States in Which Person Listed Has Solicited or Inlends to Solicit Purchasers

(Check "Al l Stat es " o r check ind iv idual Stat es ) . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..

DA ll S ta te s

. I

IALI IAK.:I IAZI IARI ICAI Icol IcT! 10EI loci IFLIilGAI o m []TI

WJ IINI 1m IKSI IKYI ILA]' .IMEI IMO] IMA] [ill] ,IMNI IMSI IMOI

IMTI INEI INYI r s m tsn INMI INYI INC] INOI 10HI i lQKI 10RI IPAIj

ill] Iscl 1501 ITNI ITXI IUTI lyTl IVAI IWAI Iwvl ,IWII IWyl IPRII'

Full Nam e (Last nam e first, if individual)

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


States in Which Person Listed Has Solicited or Intends to Solicit PurchasersI

(Check "All States" or check individual States) "" " "" " " " ..~ " .. D A ll S ta te s

IALI IAK I IAZI IARI ICAI Icol ICTI 10EI loci tm , IG AI O lD [ill]

[KJ liNd [MJ IKSI IKYI ILAI IMEI IMOI IMAI [ill] IIMNI IMSI IMOI

IMTI INEI INYI INHI lliIJ INM] INYI INCI INOI 10HI '10K] lOR] IPAI

[ill Iscl Isol ITNI ITXI IuTi IVTI IVAI IWAI Iwvl L W J IWyl IPRI

"

Full Nam e (Last nam e first. if individual)

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


States in Which Person Listed Has Solicited or Intends to Solicit Purchasers

(Ch eck "A ll S ta te s" o r check i nd iv id ua l S ta te s) . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. : .. .. .. .. .. .. .. . D A ll S ta te s

IALI IAKI IAZI IARI ICAI Icol ICTI IDEI loci IFLI IIGAI o m [Jill

[KJ IIN'I O A J [K[] IKYI ILAI IMEI IMDI IMAI [MIJ IMNI IMSI IMOI

IMTI [NEI [Nvi INHI [N[] INMI INYI INCI INOI 10HI lOKI ]oR I IPAI

ill] Isci Isol ITNI ITxl ]uTI lyTl IVAI IWAI Iwvl IIWII IWYI IPRI

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

30f9



I. Enter the aggregate offering price of securities included in this offering and the total am ount already

sold. Enter "O '~!ifthe answer is "none" or "zero." lethe transaction is an exchange offering, check

this bo x 0and indicate in the colum ns below the am ounts of the securities offered for exchange and

a lr ea dy e xc ha ng ed .

T yp e o f S e~ ur ity

Aggregate

O ff er in g P ric e

Debt :: , $__ ..;.___

Equity L $__ -,- __

o Common 0 Preferred

Con ve rti ble S ec ur it ie s ( in cl ud in g w a rr an ts ) $ _

Partnership, Interests , , $__ -'- _

Othe r (Spe :C i fy LLC UNITS ) , , $ 400,000.00

Toi~1 ."., ,', , ,', ,', ,', ',., '" " ' ' $ 400,qOO.00;;

;~A nsw er also in A ppendix, C olum n 3, if filing under U LO E.

2. Enter the num ber of accredited and non-accredited investors who have purchased securities in this

offering and the aggregate dollar am ounts of their purchases. For offerings under Rule 504, indicate

the number of persons who have purchased securities and the aggregate dollar amount of their

purchases on the total lines. Enter "0" if answ er is "none" or "zero."

Number

Investors; i I

Accredited Investors " , , , , _1_3 _!i

Non-accri~dited Investors , , " ,., .

Total (for filings under Rule 504 only) _1_3_...:.... _I

Answer also in Appendix. Column 4, if filing under ULOE.

"3. If this filing is for an offering under R ule 50 4 or 505, e nte r th e info rm ation req ue ste d for a ll se cu rities

sold by the issJer, to date, in offerings of the types indicated, in the tw elve (12) months prior to the

first sale of securities in this offering. Classify securities by type listed in Part C - Q uestion I .:.

Type of

Securityype of Offering

~Rule 505· , " _

Regulatio:h A , , " " .--'----

Rule 504,: , __ -'-- __

Total , , , , , __ -'- _

4 a. Furnish a' statement of all expenses in connection with the issuance and distribution of the

securities in this offering. Exclude am ounts relating solely to organization expenses of the insurer.

The inform ation may be given as subject to future contingencies. If the amount of an expenditure is

not known, furnish an estimate and check the box to the left of the estimate. .~i

Transfer Agent's Fees , , " , , , ..J

Printing and Engraving Costs , , " , 1 . . .

Legal Fees , " " , , , , "" " .

Accounting Fees " ,"" , " , " " , , , " , , " ! .

Engineering Fees " .. " , " , , ,,, , ' .

SI C i, ,. ( 'f fi d '~ 1 ) Ia es ommlSSlOns speci y 1R ers ees separate y " " : .

Other Expenses (identify) " " .

T I 'ta, " , " ,', " ," , ,", '." , ;'"

4 of9

J

Amou nt A lr ea dy

Sold

$_----

$_----

$_----

$_---

s 400,000.00

s 400,000.00

Aggregate

D o ll ar Amou nt

o f Pu rch as es

s 400,000.00

$_----

s 400,000.00

D olla r A m ou nt

Sold

$_----

$_----

$_----

s 0.00

0 s

0 s

0 s 20,000.00

0 s

0 s

0 s 20,000.00

0 S

0 s :40,000.00



, , .,;:r"! ;<···· "). .,-~.. , .. ;.c:,_'. ; :.,,,; , ;:0 . , •• . : •...• 0 ';-.0 ~~:,·lo:',:; ,3.",';"J":,).., '.,"~~ .•":::."; .....~;:.~:.•

. .C. OFFERING:PRICE,NUMBER·OF INVESTORS~EXPENSES AND USEiOF, PRO<::EE~S :~";"•. L . ~ft. :-:~'· .- .~~~;:.." .' ~~ ..... .~" .,: " :"_ , .C:.' .,:~ ~ .~ ' .... ~ ~ .~ . ' .... '

h. Enter the difference between the aggregate offering price given in response to Part C - Question I

and total expenses furnished in response to Part C - Question 4.a. This difference isthe "adjusted gross

proceeds to the issuer." .

5. Indicate below the amount of the adjusted gross proceed to the issuer used or proposed to be used for

each of the purposes shown. If the amount for any purpose is not known, furnish an estimate and

check the box to' the left of the est imate. The total of the payments listed must equal the adjusted gross

proceeds to the issuer set forth in response to Part C - Question 4.b above.

s 360,000.00

Payments to

Officers,

Directors, &

Affiliates

Salaries and fe~s 0$~_~ __

Purchase of real estate · ·..·· ·· ··0$_...,...- _

Purchase, rental or leasing and installation of machinery

and equipment ·············.·.··.·.·..0$ _

Construction or leasing of plant buildings and facilities 0$_-,- _

Acquisition of other businesses (including the value of securities involved in this

offering that may be used in exchange for the assets or securities of another

issuer pursuant to a merger) 0$_-,- _

Repayment of indebtedness 0$_-,- _

Working capital 0$_-'-- _

Other (specify): VENTURE CAPITAL INVESTMENTS 0$ _

Payments to

Others

0$----

0$----

0$----

0$----

0$----0$----

0$----o S 360,000.00

___ ----"'--- 0S _ D S . _

o S 360,000.00olumn Totals 0S _ O _ . O _ O _

Total Payments Listed (column totals added) .

, ,: .:,.~·.~>I~·;.

The issuer has duly caused this notice to be signed by the undersigned duly authorized person. Ifthis notice is filed under Rule 50S, the followingsignature const itutes an undertaking by the issuer to furnish to the U.S. Securit ies and Exchange Commission, upon written request of its staff.

the information furnished by the issuer to any non-accredited investor pursuant to paragraph (b)(2) of Rule 502.

Issuer (Print or Type)

AFFINITY VENTURES CAPITAL FUND I,LLC

Name of Signer (Print or Type)

ROBERT O. MCDONALD

Title of Signer (Print or Type)

PRESIDENT OF AFFINITY VENTUR

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

S of9



r u

I. Is any party described in 17 CFR 230.262 presently subject to any of the disqualification Yes No

provisions. of such rule? :..;............ !h i ~

See Appendix, Column S, for state response.

2. The under~igned issuer hereby undertakes to furnish to any state administrator of any state in which this notice is filed a notice on Form

D (17 CF~ 239.500) at such times as required by slate law. !

3. The undersigned issuer hereby undertakes to furnish to the state administrators, upon written request, information furnished by the

issuer to offerecs. .

,.

4. The undersigned issuer represents that the issuer is familiar with the conditions that must be satisfied to be entitled to the Uniform

limited Offering Exemption (ULOE) of the state in which this notice is filed and understands that the issuer claiming the availabili ty

of this exe:mption 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 behalfby the undersigned

duly authorized person.I

Issuer (Print or Type)i.

AFFINITY VENTURES CAPITAL FUND I, LLC

Name (Print or Type)

ROBERT O. MCDONALD

Date

PRESIDENT OF AFFINITY VEN URES CAPITAL FUND I, LLC

'1·

i'

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 Form

D must be manually signed. Any copies not manually signed must be photocopies of the manually signed! copy or bear typed or printed

signatures.

'J .

60f9



r

,

I ~ ~ ~ " ,j, : ; : ; , j ; " ~ " , ~ r ~ F / ; ,, : · : ; 1 ' · ~ ~ j ; ~ . : . d , . ~ 1 ~ 1 ~0ii lt lM:L;,~i irJib;:4;J,$;;; ':~PPgN P.!~~ii l/~!, ;Jj~J1/J1 Jj~¥lt~(5~~~~ ,?[,tl1:~~:~,~-i";~~~~~~~j ~j" ,,' .,' " 'O:;JT:,'Fli:<I;"""';> I,,,::,;,,:Uh'l4;'~i:' , " ' " " C , : • ' ( l,w' .. ,

,I 2 3 4 5

IDisqualification

Type of security under State ULOE

Intendto sell and aggregateI

(if yes, attach

to non-atcredited offering price Type of investor and explanation of

investors 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 1)I

Number of Number of

I Accredited Non-Accredited

State Yes No Investors Amount Investors Amount Yes No

AL I II I I I . , J

AK I 0DAZ

I D I

AR I , _ , _ " J [ _ J I 11__j

I I

I

l_D

A

CO I I I [ IDCT I I I l_[_j

I II

l__j0E

DC , . J I I 0DFL I 1 ' - _ _ 1 I c=J l_jGA I I _ I l_CJ.

HI [I l_l I

JD [ I l__j CJIL I I 0DIN I I

I

I 11__jI

[ _ _ _ _ j l__jA' I

_J ----

KS I I [ I I DDKY I I I I

l__j I

LA I I!

l_D,

0DE

,

MD : I II l_j I I

MA _j [ II IMI I ' I I I

I

I IDMN [ ' I

I

0DMSD J 01

"70f9



: . O l · » » » > · f > , · " > . . _' ..;~:~ · . > ~ ' A P P E N D i x } , ; < » " .:.,·t:,:": '..:.::iiFt'~i'.;:>' :",·;:·,:;~Y'."-:T0'~:~./c.~':1~ . '.,,' '. . ,.. .. ....: .... ,,;:,~:. ,' .:G,: " -e ,,~':;::;'/" '" .

1 2 3 ~ 4 5

Disqualification

Type of security under State ULOE

Intend to sell and aggregate (if yes, attach

to non-accredited offering price Type of investor and explanation of

investors in State offered in state amount purchased in State waiver granted)

(Part Bvltem I) (part C-Item I) (Part C-Item 2) (Part E-Item I)

Number of Number of

Accredited Non-Accredited

State Yes No Investors Amount Investors Amount Yes No

MO I I I I [ 10MT I I I I [ I

NE I I I I 11_jNY _ j l l [_j I I

NH

I I I I l_INJ [ I ! I IDNM I I I I I I I

NY I I I I I INC I I l_DND [ I I I 11__j

OH I I I I I I 10I IK II j

OR [ I I IPA I IDRI I I 011 ISC J J I I [

SD I I I 11_jTN : I I I [ ITX I I I D IUT I OJ IVT _ I _j I 10VA : I I l__j............ :

WA I IDWV I I I l_WID I 00

80f9



,,

.i,

2

Intend'to sell

to non-accredited

investors in State

(Part B-Item I)v

No

I I

Number of

Non-Accredited

Notate Yes

, 4 5

Disqualification

under State ULOE

(if yes, attach

explanation of

waiver granted)

(part E-Item I)

3

Type of security

and aggregate

offering price

offered in state

(Part C vltem I)

Type of investor and

amount purchased in State

(Part C-Item 2)

Number of

Accredited

Investors Investors Amountmount Yes

WY

I IR

,i,

. ,

~,.

I 10

90f9

Documents

SEC Form D Affinity Ventures Capital Fund I SB-5