SEC Form D Altus Venture Capital Fund IV 020106

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

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UNITED STATESSECllRITIES AND EXCHANGE COMMISSION

Washington, D.C. 20549OMB APPROVAL

FORM 0

FORM 0 OMB Number: 3235-0076Expires:Estimated average burdenhours per response 16.00NOTICE OF SALE OF SECURITIES SEC USE ONLY

06024837 PURSUANT TO REGULATION D,Prefix I

ISertat

SECTION 4(6), AND/OR DATE RECEIVEDUNIFORM LIMITED OFFERING EXEMPTION I " , I/' ";,

N am e of O ffe ring (0check if this is an am endm ent and name has changed, and indicate change.) f/"{/ ~y \..0

A. BASIC IDENTIFICATION DATA

Telephone N um ber'(!!} uding A rea Code)(580) 480-1320

ALTUS VENTURE CAPITAL FUND IV LLCfiling U nder (C heck box(es) that apply): 0 R ule 504 0 R ule 505 I{] R ule 506 0 S ec tio n 4 (6 )T yp e o f F ilin g: 0 N ew F iling 0 Amendment

I. Enter the inform ation requested about the issuerN am e o fls su er (0 check if this is an am endment and name has changed , and indicate change.)ALTUS VENTURE CAPITAL FUND IV, LLC

A dd re ss of P rinc ip al B usine ss O pe ra tio ns(if d iffe re nt fro m E xe cutiv e O ffic es)

(N um ber and Street, C ity , State, Z ip Code) T elephone N um ber (Including A rea C ode)

A dd re ss of E xe cutiv e O ffice s120 W. BROADWAY, ALTUS, OK 73521

(Number and Street, C ity, State, Z ip C ode)

B rie f D es crip tion o f B usine ssPASS THROUGH VENTURE CAPITAL ENTITYT yp e o f B us in es s O rg an iz atio no corporationo b us in es s tr us t o lim ite d pa rtne rsh ip, a lre ad y form edo lim ited partnership , to be form ed THOM8uNI Z l o th er (p le as e s pe cif y) F INANI, 'ted Li.abf.Li.t; CfAl.ffil. l l l Y canpany

Month YearA ctual or E stim ated D ate of lncorporation or O rganization : [[l2J ~ IL lActual 0 EstimatedJurisdiction of Incorporation or O rganization : (E nter tw o-letter U .S . Postal Serv ice abbreviation for State:

C N for C ana da ; F N fo r oth er foreign jurisd ic tion ) [JI]GENERAL INSTRUCTIONSFederal:Who Must File. A ll issuers m aking an offering of securities in reliance on an exem ption under R egulation D or Section 4(6),17 CF R 230.501 et seq . or 15 U.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 deem ed filed w ith the U .S. Securitiesand Exchange Comm ission (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 m ail to that address.Where To File: U S Securities and E xchange C om mission, 450 Fifth Street, N .W ., W ashington , D .C . 20549.Copies Required: Five (5) conies of this notice must be filed w ith the SEC , one of which must be m anually 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 in formation requested . A mendments need only report the nam e 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 w ith 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 ofa 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.r-----------------ATTENTON----------------,

F ailu re to file n otice in th e ap pro pr ia te s ta tes wi l l no t resu lt in a lo s s o f th e fede ra l exem ption , Conve rse ly , fa ilu re to file th ea pp ro pria te fe de ra l n otic e wi l l no t resu lt in a lo ss o f a n av a ilab le s ta te exem ption un le ss such exem ption is p red ic ta ted on th efilin 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 OMS control number. J of 9


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A. BASIC IDENTIFICATION DATA2. Enter the inform ation 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 m ore of a class of equity securities of the issuer. Each executive officer and director of corporate issuers and of corporate general and managing partners of partnersh ip issuers; and Each general and m anaging partner of partnership issuers.

C heck B ox(es) that A pply: o Promoter o B eneficia l O wne r 0 E xe cu tiv e O ffic er 0 Director I Z l G en er al a nd /o rM an ag in g P artn er

Full N am e (Last nam e first, if individual)OKLAHOMA INDUSTRIAL VENTURE MANAGEMENT COMPANY, 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 IlJ B eneficia l O wne r 0 E xe cu tiv e O ff ic er 0 Director o G en era l a nd /o r

M an ag in g P artn 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 IlJ B eneficia l O wne r 0 E xe cu ti ve O ff ic er 0 Director o G en er al a nd /o r

M an ag in g P ar tn erFull N am e (Last 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 eneficia l O wne r 0 E xe cu tiv e O ffic er 0 Director o G en er al a nd /o r

M an ag in g P artn 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 B ox(es) that A pply: o Promoter o B ene fic ia l O wne r 0 E xe cu ti ve O ff ic er 0 Director o G en er al a nd /o r

M an ag in g P artn erFull N am e (Last 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 w ne r 0 E xe cu ti ve O ff ic er 0 Director o G en er al a nd /o r

M an ag in g P artn er

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

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

C heck B ox(es) that A pply: o Promoter o B en ef ic ia l O w ne r 0 E xe cu tiv e O ffic 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, C ity , State, Zip Code)

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

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B. INFORMATION ABOUT OFFERINGYes No

I. H as the issuer sold, or does the issuer intend to sell, to non-accredited investors in this offering? ... ".""""",,.,,........ C 00Answer also in Appendix, Column 2, if filing under ULOE.

2. W hat is the minimum investment that will be accepted from any individual? .. ""."" .... " " .. ".""" .. ".".,,. ""." ... """ .. " .. $ 10,000.00Yes No

3 . D oes the offering perm it joint ow nership of a single unit? "" ....... """ .. " .. """ ...... "."." ...... "" ....... "."".,,"",, ......... ,," .. ,,.. Ii! bl4. 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 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, City, 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(C heck " All S tates" or ch eck in dividu al States) " ." .. "." ......... " "" ...... " " ... " . . "." "" " .. """ " .... " . .. ,, ......... " ",,.,, .. ,, .. "." ... " o A ll S tat esIALI IAKI IAZI IARI ICAI Icol ICTI IDEI loci [TIJ IGAI []I] [ill]illJ [lli] [IT] IK sl IKYI ILAI IMEI IMol IMAI IMII IMNI IMSI IMOIIMTI INEI INVI INHI [ill] INMI INYI INCI INOI 10HI I~ I 10RI IPAI[KO Isci 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 Which Person Listed Has Solicited or Intends to Solicit Purchasers

(Check "A ll States" or check individual States) ... " """ .... " """ ... " ""."" ... """ ... ,,."""",,""",, .. ,,""",,.,, .. " . . . . . . . . . . . . . . . . . . . . . . . o A ll S tat esIALI IAKI IAZI IARI ICAI leol I eT i 10EI loci IFLI IGAI o m [ill]O!J [lli] O A J IKSI IKYI ILAI IMEI IMDI IMAI IMII IMNI IMSI IMOIIMTI INEI INVI INHI [ill] INMI INYI INCI INOI 10H I lOKI 10RI IPAI[KO Isci ISDI ITNI ITXI IUT) IVTI IVAI IWAI Iwvl IWI) IWY) 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 ta te sIALI IAKI IAZI IAR) ICAI Icol ICTI IDEI IDCI IFL! IGAI o m [ill]O!J [ill] O A J IKSI IKYI ILAI IMEI IMDI IMAI IMII IMNI IMSI IMOIIMTI INEI INVI )NHI IN} I INMI INYI INCI INol 10H I lOKI 10RI IpAIDill !Kl Isol ITNI ITX! IUT! IVTI IVAI IWAI Iwvl IWII IWyl IPRI

(U se blank sheet, or copy and use additional copies of this sheet, as necessary.)3 of 9


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C. OFFERING PRICE, NUMBER OF INVESTORS, EXPENSES AND USE OF PROCEEDSI. Enter the aggregate offering price of securities included in this offering and the total am ount already

sold. Enter "0" if the answer is "none" or "zero." If the transaction is an exchange offering, checkth is b ox 0and indicate in the colum ns below the am ounts of the securities offered for exchange anda lr ea dy e xc ha ng ed .

T yp e o f S ec urityAggregate

O ff er in g P ri ceAmou nt A lr ea dy

SoldDebt $ _Equity $ _o Common 0 PreferredCo nv er ti bl e S e cu ri ti es ( in cl ud in g w a rr an ts ) $ $ _Pa rt ne rs h ip In te r es ts $ $ _O th er (S pe cify lim ite d lia bility c o u nits) $ 14,420,000.00 $ 14,420,000.00

Total $ 14,420,000.00 $ 14,420,000.00Answer also in Appendix, Column 3 , if tiling under ULOE.

2. Enter the num ber 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 Iines. Enter "0" if answer is "none" or "zero."

NumberInvestors

A c cr ed ite d I nv es to rs _1_0_1 _Non-accredited Investors .=.0 _

Total (for filings under Rule 504 only) .:.0 _Answer also in Appendix, Colum n 4, if filing under ULOE.

3. If this filing is for an offering under R ule 504 or 505, enter the inform ation requested for all securitiessold by the issuer, to date, in offerings of the types indicated, in the twelve (12) m onths prior to thefirst sale of securities in this offering. Classify securities by type listed in Part C - Question I.

T yp e of O fferin gRule 505 .

Type ofSecurity

.................................................................................................... _-----Regulation 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 information m ay be given as subject to future contingencies. If the am ount 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 separately) .O ther Expenses (identify) .

Total .

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$_----$_----

AggregateDo ll ar Amoun to f Pu rch as es

$ 14,420,000.00$ 0.00$ 0.00

Dolla r Amou ntSold

$ 0.00$ 0.00$ 0.00$ 0.00

0 $0 $ 4,189.320 $ 104,781.110 $0 $0 $ 714,000.000 $0 $ 822,970.43


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C. OFFERING PRICE, NUMBER OF INVESTORS, EXPENSES ANDUSE OF PROCEEDSb . Enter the difference betw een the aggregate offering price given in response to Part C - Question Ia nd total expenses furnished in response to P art C - Q uestion 4.a. T his differen ce is the "ad justed grossproceeds to the issuer." ..

5. Ind icate below the am ount of the adjusted gross proceed to the issuer used or proposed to be used foreach of the purposes shown. If the am ount fo r any purpose is not known, fu rnish an estimate andcheck the box to the left of the estim ate. The to tal 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.

$ 13,597,029.57

P aym ents toOfficers.

Directors, &Affiliates

Paym ents toOthers

S alaries a nd fees [t J $ 1,973,980.( D$_0_._00 _P urchase o f real estate D $ D $ _P urchase, re ntal or leasing and installa tion of m achin erya nd e qu ipm en t D$ _ D$----C onstruction or leasing of plant buildin gs and fa cilities D$ _A cquisition of other businesses (including the value of securities involved in thiso ffering that m ay be used in exchange for the assets or securities of anotherissuer pursuant to a m erger) D$ _R ep ay me nt o f in de bte dn ess D $ _Wo rk in g c ap ita l D $ _O th er ( sp ec if y) : VE NT UR E C APITA L IN VES TM EN TS D$ _

D$----D$----D$----D$----~ $ 11,188,049.57

o $ 435,000.00_R_E_S_E_R_V_E ... . . .. D $ _C olum n Totals ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 1,973,980.00 I Z l$ 11,623,049.57

Ii1 $ 13,597,029.57Total Payments L isted (colum n tota ls added) .D. FEDERAL SIGNATURE

The issuer has duly caused this notice to be signed by the undersigned duly authorized person . If this no tice is filed 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 par ph (b)(2) of Rule 502.

Datessuer (Print or Type)ALTUS VENTURE CAPITAL FUND IV. LLC

Nam e of Signer (Print or Type)Paul H. Doughty

T Itle of Signer (P rint or Type)President, A ltus V enture C ap ita l Fund IV . LL C

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

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E. STATE S IGNATUREI. Is any party described in 17 CFR 230.262 presently subject to any of the disqualification

provisions of such rule? .Yes[! d

No~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 FormD (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 the

issuer to offerces.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 authorized person.Issuer (Print or Type)ALTUS VENTURE CAPITAL FUND IV, LLC

Date ~-/- 2o(JbName (Print or Type)

Paul H. Doughty President, Altus Venture Capital Fund IV, 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.

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APPENDIX2

Intend to sellto non-accreditedinvestors in State(Part B-Item J)

3Type of securityand aggregateoffering priceoffered in state(Part C-Item J)

4

Type of investor andamount purchased in State

(Part C-Item 2)

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

Notate Yes NoAL I IAK

AZ

AR I . L . . . . . ._-

Number ofAccreditedInvestors Amount

Number ofNon-Accredited

Investors Amount Yes

C ,co ICT :DE

, ", .. . -..,.._,.-,'-- '-DC ! i IFL I ---,.,'GA j

IDIL 1 ,_IN 1 _ I I iIA

C=ILA

ME CDMD I IMAMI L CMSCC."

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MO

.....

2

In ten d to sellto non-acc red it edin ve sto rs in S ta te( Par t B - It em I)

3T yp e o f se cu ritya nd a gg re gat eo ff er in g p ri ceo ff ere d in s ta te(P art C -Item I)

..APPENDIX

Number ofAccreditedInvestors

4

T yp e o f inv esto r an dam ou nt p urch ased in S tate

( Par t C - It em 2)

Amount Amount

5Disqualificationu nd er S tate U LO E( if y es , a tt ac he xp la na tio n o fwa ive r g r an te d )( pa rt E -J tem I)

State Yes NoNumber of

Non-AccreditedInvestors Yes No

IMTNE L .

r .'CNVNH C "NM 1_ ~

NCL . . . j IY

NDOH

OK I . . I . !ORPA r ........._ .. '" - . - L . ._ _. . I .I . . IRIsciSDTN I . . . . .TXUT [~--'--'-~ .....VT I .VA IWAWVW I

r-I1 .. 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 j I I ,ePR I I ~ _ " " - , , , I _ , ~ _ _ _ - - ! L _ " , L , _ _ _ _- -,

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SEC Form D Altus Venture Capital Fund IV 020106

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