SEC Form D Affinity Ventures Capital Fund I

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

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UNITED STATESSECllRITIES AND EXCHANGE COMMISSION

Washington, D.C. 20549OMB APPROVALOMB Number: 3235-0076Expires:Estimated average burdenhours per response 16.00ORM D

NOTICE OF SALE OF SECURITIESPURSUANT TO REGULATION D,SECTION 4(6), AND/ORUNIFORM LIMITED OFFERING EXEMPTION

SEC USE ONLYPrefix I I Serial

D A TE R EC E IV E DI IName of Offering (~c ck if this is an amendment and name has changed, and indicate change.)AFFINITY VENTUE CAPITAL FUND I LLC

Filing U nd er (C heck box(es) t ha t a ppl y) : 0 Rule 504 0 Rule 505 0 Rule 506 0 Section 4(6) 0 ULOET ype o f Filin g: 0 N ew F ilin g 0 Amendment

1. Enter the information requested about the issuerA. BASIC IDENTIFICATION DATA

0 8 0 2 1 1 1 7am e of Issuer (0 check if this is an amendment and name has changed, and indicate change.)AFFINITY VENTURES CAPITAL FUND I, LLC

A dd ress o f P rinc ipa l B usin ess O peratio ns(if differen t fro m E xecu tiv e O ffic es)

Address of E xecutive O ffices (Number and Street, C ity, State, Zip Code)211 NORTH ROBINSON, SUITE 200, OKLAHOMA CITY, OK 73102

(N um ber and Street, City, State, Zip C ode)

Telephone N um ber (Including A rea C ode)(405) 235-5700

Telephone N um ber (Including A rea Code)

B rief D escrip tio n o f B usin essPASS THROUGH VENTURE CAPITAL ENTITYT yp e o f B us in ess O rg an iz at io no corporationo b us in es s t ru st o lim ited p artn ersh ip , alread y fo rm edo lim ited partn ersh ip , to b e fo rm ed ii/W!nC\tl~lf'1'~nrn h (I if ) U n~,J,'"JI\JIU'\J~ ot er p e ase spec! y : r e ~ ~ . 0 / ' \ f i : n : ; n nlimitedliability ~~J""il#\l

M onth YearA ctua l or E stim ated D ate o f Inc orp oration or O rg an ization : [[I9] ~ [ ; z j Actual 0 EstimatedJurisdiction of Incorporation or O rganization: (Enter tw o-letter U .S. Postal Service abbreviation for State:

C N for C an ad a; F N for o th er fo reig n ju risd iction ) I I l I EGENERAL INSTRUCTIONSFederal:Who Must File: A ll Issuers m aking an offering of securities in reliance on an exem ption under Regulation D or Section 4(6),17 CF R 230.501 et seq. or 1 5 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 mailed by United States registered or certified mail to that address.Where To File: U .S. S ecu rities an d E xch an ge C om missio n, 450 Fifth Street, N .W ., W ashington, D .C . 20549.Copies Required: Five (5) 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 manually 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 Appendix neednot be filed with the SEC.Filing Fee: There IS no federal filing fee.State:This notice shall be used to indicate reliance on the Uniform Limited Offering Exemption (U LOE) for sales of securities in those states that have adoptedULOE and that have adopted this form . Issuers relying on ULOE must tile a separate notice with the Securities Administrator in each state where salesarc to be, or have been made. If a 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 with state law . The Appendix to the notice constitutes a part ofthis notice and m ust be com pleted.r----------------ATTENTON----------------,

F ailu re to file n o tic e in th e a p p ro p ria te s ta te s will n o t re s u lt in a lo s s o f th e fe d e ra l e xe m ptio n . C o n v e rs e ly , fa ilu re to file th ea pp ro pr ia te fe de ra l n otic e will n o t re su lt in a lo s s o f a n a v a ila b le s ta te e x e m ptio n u n le ss s u c h e x e m ptio n is p re d icta te d o n th efilin g o f a fe de ra l n otic e.

SEC 1972 (6-02) I of9Persons who respond to the collection of information contained in this form are notrequired to respond unless the form displays a currently valid OMS control num ber.


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,A. BASIC IDENTlFIC~ nON DATA

2, Enter the information requested for the follow ing: Each promoter of the issuer, if the issuer has been organized w ithin the past five years; Each beneficial owner having the power to vote or dispose, or direct the vote o r d isposition of, 10% or m ore of a class ofcquity securities ofthc issuer. Each executive officer and director of corporate issuers and of corporate general and managing partners of partnership issuers; and Each general and managing partner of partnership issuers,

Check Box(es) that Apply o Promoter o B en efic ial O wn er 0 E xe cu ti ve O ff ic er 0 Director I Z l G en era l an d/o rM an ag in g P artn er

F ull N am e (L ast nam e first, if indiv id ual)AFFINITY VENTURES, LLCBusiness or Residence Address (Number and Street, City , State. Zip Code)211 NORTH ROBINSON, SUITE 200, OKLAHOMA CITY, OK 73102

Check Box(es) that A pply: o Promoter ~ Beneficial Owner 0 E xe cu ti ve O ff ic er 0 Director o G en er al a nd /o rM an ag in g P artn er

Full Nam e (L ast nam e first, if individual)AFFINITY HOLDINGS CORPORATIONBusiness or Residence Address (Number and Street, City, State, Zip Code)211 NORTH ROBINSON, SUITE 200, OKLAHOMA CITY, OK 73102Check Box(es) that A pply: o Promoter o B en efic ial O wn er 0 E xe cu ti ve O ff ic er 0 Director o G en er al a nd /o rM an ag in g P artn erFull N am e (Last nam e first, if individual)ROBERT 0, MCDONALDBusiness or Residence Address (Number and Street. City, State, Z ip Code)211 NORTH ROBINSON, SUITE 200, OKLAHOMA CITY, OK 73102Check Box(es) that A pply: o Promoter o B en efic ial O wn er 0 E xe cu ti ve O ff ic er 0 Director o G en er al an d/o r

M an ag in g P ar tn erFull N am e (Last nam e first, if individual)ROBERT G. RADERBusiness or Residence Address (Number and Street, City, State, Z ip Code)211 NORTH ROBINSON, SUITE 200, OKLAHOMA CITY, OK 73102

Check Box(es) that Apply: o Promoter o B en efic ial O wn er 0 E xe cu ti ve O ff ic er 0 Director o G en er al a nd /o rM an ag in g P ar tn er

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

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

Check Box(es) that Apply: o Promoter o B en efic ial O wn er 0 E xe cu ti ve O ff ic er 0 Director o G en er al an d/o rM an ag in g P artn er



Check Box{es) that Apply o Promoter o B en efic ial O wn er 0 E xe cu ti ve O ff ic er 0 Director o G en er al a nd /o rM an ag in g P ar tn er



(Use blank sheet, or copy and use additional copies of this sheet, as necessary)2 of 9


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B. INFORMATION ABOUT .OFFERING

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 under ULOE.

Ye sC

No~2. What is the minimum investment that will be accepted from any individual? ... $ 10,000.00

Yes No3. Does the offering permit joint ownership of a single unit? ,., .. D4. Enter the information requested for each person who has been or will be paid or given, directly or indirectly. any

com mission or sim i lar rem uneration for solicitation of purchasers in connection w ith sales of securities in the offering.If a person to be listed is an associated person or agent ofa broker or dealer registered with the SEC and/or with a stateor states, list the name of the broker or dealer. If more 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 Nam e (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 73102

Name of Associated Broker or Dealer

States in Which Person Listed Has Solicited or Intends to Solicit Purchasers( Ch ec k "Al l S ta te s" o r c he ck i nd iv id ua l S ta te s) .. ... ... ... ... ... ... .. .. ... ... ... ... ... ... ... ... ... . .............. "......... . . . . . . . .... . . ..., o A ll S ta te sIALI IAK I IAZI IARI ICAI Icol ICTI 1 0EI loci IFLI IGAI [}ill [JQJIJIJ [lli] e m IKSI IKYI ILAI IMEI IMOI IMAI [MIJ IMNI IMSI IMOIIMTI INEI INVI INHI O :m INMI INYI INCI INOI IOHI IQKI IORI IPAIDill Isci Isol ITNI ITX I IUTI IVTI IVAI IWAI Iwvl IWII IWyl IPRI

Full Nam e (Last name 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(C heck "A ll States" or check indiv idu al States) ..................... ...... . . . . . ...... , ........................ "................ o A ll S ta te sIALI IAK I IAZI IARI ICAI Icol ICTI 1 0EI loci IFLI IGAI o m [JQJIJIJ [lli] e m IKSI IKYI ILAI IMEI IMOI IMAI IMII IMNI IMSI IMOIIMTI INEI INVI INHI I NJ I INMI INYI INCI INOI IOH I lOK I IORI IPAIDill Isci Isol ITNI ITX I IUTI IVTI IVAI IWAI Iwvl IWII Iwyl IPRI

Full Nam e (Last name first, if individual)

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


States in Which Person Listed H as 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 ICTI 10EI loci IFLI IGAI [}ill [JQJIJIJ [lli] e m IKSI IKYI ILAI IMEI IMOI IMAI IMII IMNI IMSI IMOIIMTI INEI INVI INH I O :m INMI INYI INCI INOI IOH I lOKI IORI IPAIDill Isci []ill 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


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C. O FF ER ING P RIC E, N UMBE Rq FlN YE STOR S, E XP EN SE S A N'D USE OF PROCEEDS

I, Enter the aggregate offering price of securities included in this offering and the total am ount alreadysold, Enter "0" if the answer is "none" or "zero," Ifthe transaction is an exchange offering, checkth is b ox 0and indicate in the colum ns below the amounts of the securities offered for exchange anda lr ea dy exchang ed ,

T yp e o f S ec ur ityAggregate

O ff er in g P ri ceDebt ,.. , ,.. , , ,., '., ,.. , , , , ,. $ _

,., ,.,' '., ", ,' ' '$_----quity " , .. o Common 0 PreferredC onv er ti bl e S ec ur it ie s ( in cl ud in g wa rr an ts ) $ _Partnership Interests , " ,., ' , ,' $ _Other (Specify lim ited liability co units ,............... .. $ 2,740,000.00

Total ......, , , , .. '.', .. ,." $ 2,740,000.00Answer also in Appendix, Column 3, iffiling under ULOE.

2. Enter the number of accredited and non-accredited investors who have purchased securities in thisoffering and the aggregate dollar am ounts of their purchases, For offerings under Rule 504, indicatethe number of persons who have purchased securities and the aggregate dollar amount of theirpurchases on the total lines. Enter "0" if answer is "none" or "zero."

NumberInvestors

Accredited Investors , , ,., , , , , " , .. ,.. , , .. ,." _1 _0_0 _Non-accredited Investors ,." " " , , , ;:::0 _

Total (for filings under Rule 504 only) .. oAnswer also in Appendix, Column 4, if filing under ULOE.

3. If this filing is for an offering under Rule 504 or 505, en te r th e in fo rm atio n re qu este d fo r all se cu ritie ssold by the issuer, to date, in offerings of the types indicated, in the tw elve (12) months prior to thefirst sale of securities in this offering, Classify securities by type listed in Part C - Q uestion I.

T yp e o f O ffe rin gRule 505 ... .. .Regulation A .

Type ofSecurity

." , ,., ,." -----, ,------

Rule 504 . , , _-----Total , , , _

4 a. Furnish a statement of all expenses in connection with the issuance and distribution of thesecurities in this offering, Exclude amounts relating solely to organization expenses of the insurer.The information may be given as subject to future contingencies. If the amount of an expenditure isnot known, furnish an estimate and check the box to the left of the estimate.

Transfer Agent's Fees .. , ,.. , , " , ,.. , , ,.Printing and Engraving Costs , ,.. , .Legal Fees , , .. , , , , " ' , .Accounting Fees .Engineering Fees ,." ,." , .. ,., ,.. , , , .Sales Commissions (specify finders' fees s eparately) ..O ther Expenses (identify) _

Total , .

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Amoun t A lr ea dySold

$_----$_---$-----$-----$ 2,740,000.00$ 2,740,000.00

AggregateD olla r A m ou nto f Pu rchas es

$ 2,740,000.00$ 0.00$ 0.00

D olla r A m ou ntSold

$_----$_----$_----$ 0.00

0 $0 $ 3,005.780 $ 48,598.500 $0 $0 $ 137 ,000.000 $0 $ 188,604.28


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C. OFFERING PRICE, NUMBER OF INVESTORS, EXPENSES ANDUSE OF PROCEEDS

b. Enter the difference between the aggregate offering price given in response to Part C - Q uestion Iand total expenses furnished in response to Part C - Q uestion 4.a. T his difference is the "adjusted grossproceeds to the issuer." ..

5 . Indicate below the amount ofthe adjusted gross proceed to the issuer used or proposed to be used foreach of the purposes show n. 1f the amount for any purpose is not known, furnish an estimate andcheck the box to the left of the estim ate. The total of the paym ents listed m ust equal the adjusted grossproceeds to the issuer set forth in response to Part C - Question 4.b above.

$ 2,551,395.72

Paym ents toOfficers,Directors, &Affiliates

Paym ents toOthers

Salaries and fees 0$ 374,845.9~ 0$_0_'_00 _0$----urchase of real estate 0$ _Purchase, rental or leasing and installation of m achineryand equipment .Construction or leasing of plant buildings and facilities

.................0$----.................0$----0$----0$----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 merger) .. .. .............0$---0$----0$----0$----o $ 2,176,549.80R ep ay me nt o f in de bte dn ess 0$ _W or kin g c ap ita l 0$ _O th er ( sp ec if y) : VENTURE CAPITAL INVESTMENTS 0$ _

-------------------------- ......0$----0$----C olu mn T ota ls 0$ 374,845.92 0$ 2,176,549.80Total Paym ents Listed (colum n totals added) 0$ 2,551,395.72

The issuer has duly caused this notice to be signed by the undersigned duly authorized person. If this notice is filed under Rule 5 05 , the follow ingsignature constitutes an undertaking by the issuer to furnish to the U .S. Securities and Exchange Com mission, 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 T ype)AFFINITY VENTURES CAPITAL FUND I, LLC

Title of Signer (Print or Type)President, Affinity Ventures Capital F

Name of Signer (Print or Type)Robert O. McDonald

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

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,- . .E. STATE.SIGNATU~EI, Is any party described in 17 CFR 230.262 presently subject to any of the disqualification

provisions of such rule') " .. ,'" ''', "."', ".,' ,." "" ,.. , ,,,,' " , ..Yes[] Nog]

See Appendix, 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 Form

D (17 CFR 239.500) at such times as required by state law.

3. The undersigned issuer hereby undertakes to furnish to the state administrators, upon written request, information furnished by theissuer to offcrecs.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 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 behalfby the undersignedduly author ized person.

AFFINITY VENTURES CAPITAL FUND I, LLCDate

President, Affinity Ventures Capital Fund

Issuer (Print or Type)

Name (Print or Type)Robert O. McDonald

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.

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. '. ' A P P . E N D IX1 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-ltem I) (Part C-ltem I) (Part C-ltem 2) (Part E-Item I)

Number of Number ofAccredited Non-Accredited

State Yes No Investors Amount Investors Amount Yes NoMO - . , I I _ l I t !- . . .. 'MT L . I ! I..NE L . I 'I I I.- i I.NY ; C i,.~.NH L . . _ I-.. ..".;NJ f . . ~ _ . jD'---- ..---,I.. ~ . ~ ___ w . ~" .NM ! I I i.......NY 1 L I !.: ...... ~NC L _ . _ - _ ..' I INO 1 _ . _ _ . . L . _ _ _. [....... .. -OH . _ ,, ,. _ ._ ~ . _ . . _ .i L I L . ._ _ _ "r._ _____ ~__OK l....._: I . . . I. ......OR L . . .. .. .. .. . L.._...; . _ _ - )...............r - - -PA I i..... .-....... _ ....'RI e,l 1,SC ,. . _ . . . .1 I ! L . _ _ . . _ _ _SO I I CTN I I '! I""--"Y " -".~",-TX j I . . . . . . . . . . . . . . . :UT I I C :VT I I i I :- ' _ ' _ ..VA I I I i.. _ . - " . - - . _ . --- .,...WA 1[=.....C---~~,.--. .. . -.-WV L . . . . ._ _ CWI I I 1 . _ . . _ I I . i

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

Number of Number ofAccredited Non-Accredited

State Yes No Investors Amount Investors Amount Yes NoWY I I IPR I I l _ m ~ . . _ . _ " ; 1 _ _ - 1 _ _ _ . _ ;- .- .. -,~

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Documents

SEC Form D Affinity Ventures Capital Fund I