1. Name and Address of Reporting Person * |
Â
PRIM BILLY D |
|
2. Date of Event Requiring Statement (Month/Day/Year) 11/04/2010 |
3. Issuer Name and Ticker or Trading Symbol Primo Water Corp [PRMW]
|
104 CAMBRIDGE PLAZA DRIVE |
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
__X__ Director |
__X__ 10% Owner |
__X__ Officer (give title below) |
_____ Other (specify below) |
Chairman, CEO, President |
|
5. If Amendment, Date Original Filed(Month/Day/Year)
|
WINSTON-SALEM, NC 27104 |
6. Individual or Joint/Group Filing(Check Applicable Line)
_X_ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person
|
|
Table I - Non-Derivative Securities Beneficially Owned |
|
1.Title of Security (Instr. 4) |
2. Amount of Securities Beneficially Owned (Instr. 4) |
3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) |
4. Nature of Indirect Beneficial Ownership (Instr. 5) |
Common Stock
|
1,254,106
|
D
|
Â
|
Common Stock
|
4,791
|
I
|
See Footnote
(1)
|
Common Stock
|
4,791
|
I
|
See Footnote
(2)
|
Common Stock
|
23,957
|
I
|
See Footnote
(3)
|
Common Stock
|
23,957
|
I
|
See Footnote
(4)
|
Common Stock
|
4,791
|
I
|
See Footnote
(5)
|
Common Stock
|
4,791
|
I
|
See Footnote
(6)
|
|
1. Title of Derivative Security (Instr. 4) |
2. Date Exercisable and Expiration Date (Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) |
4. Conversion or Exercise Price of Derivative Security |
5. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 5) |
6. Nature of Indirect Beneficial Ownership (Instr. 5) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
Series A Preferred Stock
|
Â
(7)
|
Â
(7)
|
Common Stock
|
1,200,000
|
$
(7)
|
D
|
Â
|
Series A Preferred Stock
|
Â
(7)
|
Â
(7)
|
Common Stock
|
50,000
|
$
(7)
|
I
|
See Footnote
(8)
|
Series C Preferred Stock
|
Â
(9)
|
Â
(9)
|
Common Stock
|
512,363
|
$
(9)
|
D
|
Â
|
Stock Option (right to buy)
|
Â
(10)
|
11/01/2014 |
Common Stock
|
9,583
|
$
10.44
|
D
|
Â
|
Stock Option (right to buy)
|
Â
(10)
|
01/01/2016 |
Common Stock
|
21,562
|
$
10.44
|
D
|
Â
|
Stock Option (right to buy)
|
Â
(11)
|
01/25/2017 |
Common Stock
|
1,917
|
$
13.04
|
D
|
Â
|
Stock Option (right to buy)
|
Â
(10)
|
05/01/2018 |
Common Stock
|
9,583
|
$
20.66
|
D
|
Â
|
Common Stock Warrant (right to buy)
|
04/28/2006 |
04/28/2016 |
Common Stock
|
127,935
|
$
13.04
|
D
|
Â
|
Common Stock Warrant (right to buy)
|
05/31/2008 |
04/28/2016 |
Common Stock
|
4,218
|
$
13.04
|
D
|
Â
|
Common Stock Warrant (right to buy)
|
05/23/2006 |
04/28/2016 |
Common Stock
|
1,791
|
$
13.04
|
I
|
See Footnote
(1)
|
Common Stock Warrant (right to buy)
|
12/14/2007 |
12/14/2017 |
Common Stock
|
3,993
|
$
20.66
|
D
|
Â
|
Common Stock Warrant (right to buy)
|
05/20/2008 |
05/20/2018 |
Common Stock
|
917
|
$
20.66
|
D
|
Â
|
Common Stock Warrant (right to buy)
|
12/30/2009 |
12/30/2019 |
Common Stock
|
3,833
|
$
(12)
|
D
|
Â
|
Common Stock Warrant (right to buy)
|
10/05/2010 |
10/05/2020 |
Common Stock
|
1,775
|
$
(12)
|
D
|
Â
|
* |
If the form is filed by more than one reporting person, see Instruction 5(b)(v). |
** |
Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). |
(1) |
Held by Mr. Prim's spouse. |
(2) |
Held by BD Prim, LLC of which Mr. Prim is the sole manager. |
(3) |
Held by 2010 Irrevocable Trust fbo Sarcanda Westmoreland Bellisimo of which Mr. Prim is the sole trustee. |
(4) |
Held by 2010 Irrevocable Trust fbo Anthony Gray Westmoreland of which Mr. Prim is the sole trustee. |
(5) |
Held by 2010 Irrevocable Trust fbo Jager Grayln Dean Bellisimo of which Mr. Prim is the sole trustee. |
(6) |
Held by 2010 Irrevocable Trust fbo Joseph Alexander Bellisimo of which Mr. Prim is the sole trustee. |
(7) |
The Series A Convertible Preferred Stock is convertible, at any time at the holders election, into the Issuer's common stock at a ratio of approximately 1:0.0958 and has no expiration date. |
(8) |
Held by Billy D. Prim Revocable Trust of which Mr. Prim is the sole trustee. |
(9) |
The Series C Convertible Preferred Stock is convertible, at any time at the holders election, into the Issuer's common stock at a ratio of approximately 1:0.184 and has no expiration date. |
(10) |
All of these shares are fully vested and exercisable. |
(11) |
1,438 of these options are vested and exercisable. The remaining 479 options will vest on January 25, 2011 or upon the consummation of an initial public offering. |
(12) |
The exercise price of these warrants is $13.04 or, after an initial public offering of the Issuer resulting in aggregate proceeds to the Issuer of an amount greater than $30.0 million, 80% of the initial public offering price per share. |