sec form d altus venture capital fund v 110906

8/6/2019 SEC Form D Altus Venture Capital Fund v 110906

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.;;-). . .FORM D UNITED STATESSECURITIES AND EXCHANGE COMMISSION

Washington. D.C. 20549 76

,INOTICE OF SALE OF SECURITIES,PURSUANT TO REGULATION D, (SECTION 4(6), AND/OR

UNIFORM LIMITED OFFERING EXEMPTION

FORM D I I I I I H I I I l l l l l l 1 1 .0008043744

IDATE RECEIVED

r

lA. BASIC IDENTIFICATION DATA

Name of Offering (0 check if this is an amendment and name has changed, and indicate change.)ALTUS VENTURE CAPITAL FUND V LLCFiling Under (Check box(es) that apply): 0 Rule 504 0 Rule 505 0 Rule 506 0 Section 4(6)Type of Filing: 0New Filing 0Amendment

I. Enter the information requested about the issuerName of Issuer (0check if this is an amendment and name has changed, and indicate changc.)ALTUS VENTURE CAPITALfUND V, LLC

(Number and Street, City, State, Zip Code) Telephone Number (Including Area Code)

(Number and Street, City, State, Zip Code) Telephone Number (Including Area Code)(580) 480-1320

Address of Executive Offices120W. BROADWAY, ALTUS, OK 73521Address of Principal Business Operations(if different from Executive Offices)Brief Description of BusinessPASS THROUGH VENTURE CAPITAL ENTITYType of Business Organizationo corporationo business trust o l imited partnership, already formedo l imi~ed partnership. to be formed o other (please specify): P R O C E S S E DN O V 3 0 2 0 0 6

Month YearActual or Estimated Date of Incorporation or Organization: [IJJiJ IliI:!J 1 2 1 Actual 0 EstimatedJurisdiction of Incorporation or Organization: (Enter two-letter U.S. Postal Service abbreviation for State:

CN for Canada: FN for other foreign jurisdiction) ~ rnGENERAL INSTRUCTIONSFederal:Who Must File: All issuers making an offering of securit ies in reliance on im exemption under Regulation 0 or.Section 4(6), 17CFR 230.s01 et seq. or 15U.S.C.77d(6).When To File: A notice must be filed no later than 15 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 dale 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. Secur ities and Exchange Commission, 450 Fifth Street, N.W., Washington, D.C. 20549.Copies Required; Fiye (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 s igned 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 information requested in Part C, and any mater i a l changes from the information previously supplied in Parts A and B . Part E and the Appendix neednot befiled 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 (ULOE) 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 with the Securities Administrator in each state where salesare 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 fonn. 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 must be completed .....----------------ATTENTON-----------------.

Fa~ lu re to file n otice in the appropr ia te states w ill n ot resu lt in a loss of the federa l exem ption . C on verse l ..",fa ilu re to file theappropr ia te federa l n otice w ill n ot resu lt in a loss 01 a n ava ilab le s ta te exem ption un less such exem ption ' p redictated on thelilin g 0 1 a le de 'r al n otic e.

SEC 1972 (6-02) Persons who respond to the collection of information contained in this form arerequired to respond unless the form displays IIcurrently valid OMS control number. I of9


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2. Enter the information requested for the following: 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 ofa class of equity securities of the issuer .. , Each executive officer and director of corporate issuers and of corporate general and managing partners 'of partnership issuers; and

:II' ~ t Each general and managing partner of partnership issuers.

Check Box(es) that Apply: o Promoter o iBeneficial Owner 0 Executive Officer 0 Director ~ General and/orManaging Partner

full Name (Last name first , if individual)OKLAHOMA INDUST~IAL VENTURE MANAGEMENT COMPANY, LLCBusiness or Residence Address (Number and Street, City, State, Zip Code)120W. BROADWAY,ALTUS, OK 73521Check Box( esj thai Apply: III Beneficial Owner 0 Executive Officer 0 Director o General and/or

Managing Partnero Promoterfull Name (Last name first. if individual)FSB BANCORP, INC,Business or Residence Address (Number and Street, City, State; Zip Code)721 N. MAIN STREET, P.O. BOX 979, ALTUS, OK 73522-0979Check Box(es) that Apply: o Promoter III Beneficial Owner 0 Executive Officer 0 Director o General and/orManaging Partner'Full Name (Last name first, if individual)CFO MANAGEMENT, LLCBusiness or Residence Address (Number and Street, City, State, Zip Code)120 W. BROADWAY, ALTUS, OK 73521Check Boxtesj.that Apply: o Promoter o Beneficial Owner 0 Executive Officer 0 Director o General and/or

Managing Partnerfull Name (Last name first. if individual)PAUL H. DOUGHTY \Business or Residence Address (Number and Street, City, State, Zip Code)721 N. MAIN STREET, P.O. BOX 979, ALTUS, OK 73522-0979Check Box(es) that Apply: o Promoter o General and/orManaging Partnero Beneficial Owner ~ Executive Officer 0 Directorfull Name (Last name first, if individual)F. DON ANDERSONBusiness or Residence Address (Number and Street. City, State. Zip Code)I120 w . BROADWAY, ALTUS, OK 73521Check Box(es) that Apply: o Beneficial Owner III Executive Officer 0 Director o General and/or

Managing Partnero Promoter

ful l Name (Last name first . if individual)WILLIAM R. GRISSOMBusiness or Residence Address (Number and Street, City, State, Zip Code)120 W. BROADWAY, ALTUS, OK 73521Check Boxtes) that Apply: o Promoter o General and/or

Managing Partnero Beneficial Owner b Z l Executive Officer 0 Director

ful l Name (Last name first . i f individual)SIDNEY S. FARR .~Business or Residence Address ' (Number and Street, City, State. Zip Code)6500 NoW.GRAND DRIVE, OKLAHOMA CITY, OK 7~116~

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


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Yes NoL Has the issuer sold, or does the issuer intend to sell, to non-accredi ted investors in this offering? 0 ~. ~~ ~.

Answer also in Appendix, Colum n 2, if fi ling under U LO E:2. W hat is the m inim um investm ent tha t will be accepted from any individual? $ 50,000.00

Yes No3. Docs t he offering perm it joint ownership of a single unit? ,. . . . ~ [d4. Enter the inform ation requested for each person who has been or will be paid or given, directly or indirectly. any

com m ission or sim ilar rem unera tion for solici ta t ion of purchasers in connect ion w ith sales of securi t ies in the offering.If a person to be listed is an associa ted person or agent ofa broker or dealer registered w ith the SECand/orw ith a sta te .or sta tes, list the nam e of the broker or dealer. Ifm ore than five (5) persons to be listed arc associa ted persons of sucha broker or dealer, you m ay set forth the inform ation for tha t broker or dealer only.

Full N am e (Last nam e first , if individual)CAPITAL WEST SECURITIES, INC.B usi ne ss o r R esi den ce Address (Num ber and Street , C ity, S ta te , Zip Code)211 NORTH ROBINSON, SUITE 200, OKLAHOMA CiTY, OK 73102Nam e of Associated Broker or Dealer

Sta tes in W hich Person Listed Has Solicited or Intends to Solici t Purchasers(Ch ec k " ~I I S t at es " o r c he ck i nd iv id ua l S ta te s) . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . : .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. o A ll S ta te sIALI IAKI , IAZI IARI ICAI Icol ICTI IOEI loci I 1 J IGAI !Jill [ill][J1J I J R J IJA] IKSI IKvl ILAI IMEI IMDI IMAI IMII IMNI IMSI IMOIIMTI INRI INVI INHI r s n INMI INVI INcl INDI IOHI IQ,KI IORI IPAIo m Isci ISDI ITNI ITXI IUTI IVTI IVAI IWAI Iwvl IWII Iwvl IPRI

Full N am e (Last nam e. first , i f individual)

Business or Residence Address (Num ber and Stree t , C ity, S ta te, Z ip Code)

Nam e of Associated Broker or Dealer

Sta tes in W hich Person Listed Has Solicited or Intends to Solici t Purchasers(C he ck "A ll S ta te s" o r ch ee k i nd iv id ual S ta te s) " ,. .. . .. .. . .. .. . .. .. .. . .. .. . .. .. . .. .. .. . .. .. . .. .. . .. .. .. . .. .. . .. .. . .. .. .. . .. .. . .. .. . .. .. . 0 A ll S ta te sIALI IAKI IAZI IARI ICAI Icol ICTI 1 0 EI loci [ill IGAI [I[] D ID[J1J [lli] !IT] IKSI IKvl ILAI IMEI IMOI IMAI [ill] IMNI IMSI IMOIIMTI INEI INVI INHI []ill INMI INVI INCI INOI IOHI lOKI IORI IPAIo m Isci Isol ITNI ITXI IUTI IVTI IVAI IWAI Iwvl [3ffi IWyl IPRj

FuJI N am e (Last nam ~ first , if individual)

Business or Residen~e Addn:s~ (Num ber and Stree t , City, S ta te, Z ip Code)

.N arne of A ssocia ted B roker or D ealer

Sta tes in W hieh Person Listed Has Solici ted or Intends to Solici t Purchasers(Check "All Sta tes" or check individual Sta tes) 0 A ll S ta te sIALI IAKL IAZI IARI ICAI Icol [IT] 1 0E I loci I fL I 'IGAI o m lJQ][J1J m n 1m IKSj IKVI ILAI IMEI IMDI IMAI [ill] IMNI IMSI IMOIIMTI INEI INvl INHI r s n INMI INVI 'INCI INOI IOHI lOKI IORI IPAIDill [R] Isol ITNI ITXI IUTI ~ IVAI IWAI Iwvl Iwll Iwvl IPRI

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


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5.

b. Enter the difference between the aggregate offering price given in response to Part C- Question Iand total expenses furnished in response to Parl C - Question 4.a. This difference is the "adjusted grossproceeds to the issuer." .

, ~. . . ~Indicate below the amount of the adjusted gross proceed to the issuer used or proposed to be used foreach o f the purposes shown. If the amount for any purpose is not known. furnish an estimate andcheck the box to the left of the estimate. The total of the payments listed must equal the adjusted grossproceeds to the issuer set forth in response to Part C - Question 4.b above.

$ 22,123,339.39

Payments toOfficers,Directors, &Affiliates

Saiaries and fees .. ': ".0 $ 3,221,285.(Purchase of real estate " " " : "." " " 0$ . _Purchase, rental or leasing and installation of machineryand equipment : " "" " ; 0$ . _. Construction or leasing of plant buildings and 'facil ities 0$ , _Acquisit ion of other businesses (including the value of securit ies involved in thisoffering that may be used in exchange for the assets or securities of anotherissuer pursuant to a merger) : " 0$ . _Repayment of ind~btcdness " " "" " ; 0 $ . _Working capital , " " : 0 $ , _Other (specify): VENTURE CAPITAL INVESTMENTS 0s _

Payments toOthers

OS 0.000$

0$OS

OS0$0$OS 18,902,054.39OS----------'---'-------------- 0$----

Column Totals ; OS 3,221,285.000$ 18,902,054.39Total Payments Listed(column totals added) 0$ 22,123,339.39

The issuer has duly caused this notice to be signed by the undersigned duly authorized person. If this notice is filed under Rule 505, the followingsignature constitutes an undertaking by the issuer 10 furnish 10 the U.S. Securities and Ex nge Commission, upon written request of its staff,the information furnished by the issuer to any non-accredited investor pursuant to p 'ph b) ) of Rule 502.o .Issuer (Print or Type) IALTUS VENTURE CAPITAL FUND V, LLC

Date //- 'l-t7,6Name of Signer (Print or Type)Paul H. Doughty

Tit e of Signer (PrintPresident, Altus Venture Capital Fund V, LLC

r-----.------;---------'-----:--- ATTENTION ---------------,Intentional misstatements or omissions of fact constitute federal erlmlnal violations. {See 18 U.S.C. 1001.)

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,I. Is any party described in 17 CFR 230.262 presently subject to any of the disqualification Yes Noprovisions of such rule? :................................................................................................................... I ! d ~

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 issuerhereby undertakes to furnish to the state administrators, upon written request, information furnished by the

issuer to offerees.4. The undersigned issuer represents thar'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 authorized person.Issuer (Print or Type)ALTUS VENTURE CAPITAL FUND V, LLC

Date //- ~-O,bName (Print or Type)Paul H~'Doughty , President, Altus Venture Capital Fund V, LLC

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

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,, .42 3 ., 5

I;' r 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-Jtem 2) (Part E-Item I)

Number of Number ofAccredited Non-AccreditedState Yes No Investors Amount Investors Amount Yes NoMO LJI ' I IDMT j I I I 10NE ! I 1 10NV I I j INH I II I IDNJ I I I : I IDNM I I I I I I I INY I ' I I i I INC I ' I I I I IND I I , I II IOH 01 I IDOK I~ I ' I I I IOR J I I I IPAC I IDRI 011 ISC .. I II ISD I L J I ITN ! , . I I I I iTX I 0r:u r [ Dv r I . [ _ _ _ I 10VA I I 1 I I IWA ! I I I 10WV I II I I I IWI CJ0 DD

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,2

I ntend to se11to non-accreditedinvestors in State(Part B-Item I)

3 't'Type of securityand aggregateoffering priceoffered in state(Part C-Item I)

4

Type of investor andamount purchased in State

(Part Csltem 2)

5Disqualificationunder State ULOE(if yes, attachexplanation ofwaiver granted)(Part E-Item 1)

State Yes NoNumber ofAccreditedInvestors

'Number ofNon-Accredited

Nonvestorsmount Ye smountWy IIIDPRDC DO

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sec form d altus venture capital fund v 110906

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