SEC FORM
3
SEC Form 3
| FORM 3 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934
or Section 30(h) of the Investment Company Act of 1940
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| OMB APPROVAL |
| OMB Number: |
3235-0104 |
| Estimated average burden |
| hours per response: |
0.5 |
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1. Name and Address of Reporting Person*
| 3000 SAND HILL ROAD, 4-250 |
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(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
07/27/2010
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3. Issuer Name and Ticker or Trading Symbol
GREEN DOT CORP
[ GDOT ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
|
Director |
X |
10% Owner |
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Officer (give title below) |
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Other (specify below) |
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5. If Amendment, Date of Original Filed
(Month/Day/Year)
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6. Individual or Joint/Group Filing (Check Applicable Line)
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Form filed by One Reporting Person |
| X |
Form filed by More than One Reporting Person |
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| Table I - Non-Derivative Securities Beneficially Owned |
|---|
| 1. Title of Security (Instr.
4)
|
2.
Amount of Securities Beneficially Owned (Instr.
4)
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3. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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4. Nature of Indirect Beneficial Ownership (Instr.
5)
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Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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|---|
| 1. Title of Derivative Security (Instr.
4)
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2. Date Exercisable and Expiration Date
(Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr.
4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
|
6. Nature of Indirect Beneficial Ownership (Instr.
5)
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| Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
1. Name and Address of Reporting Person*
| 3000 SAND HILL ROAD, 4-250 |
|
(Street)
|
1. Name and Address of Reporting Person*
| 3000 SAND HILL ROAD, 4-250 |
|
(Street)
|
1. Name and Address of Reporting Person*
| 3000 SAND HILL ROAD, 4-250 |
|
(Street)
|
1. Name and Address of Reporting Person*
| 3000 SAND HILL ROAD, 4-250 |
|
(Street)
|
1. Name and Address of Reporting Person*
| 3000 SAND HILL ROAD, 4-250 |
|
(Street)
|
1. Name and Address of Reporting Person*
| 3000 SAND HILL ROAD, 4-250 |
|
(Street)
|
1. Name and Address of Reporting Person*
| 3000 SAND HILL ROAD, 4-250 |
|
(Street)
|
| Explanation of Responses: |
| Remarks: |
|
| No securities are beneficially owned. |
|
By SCFF Management LLC, its General Partner,
By Douglas M. Leone, its Managing Member
By /s/ Melinda Dunn as attorney-in-fact |
08/06/2010 |
|
By /s/ Melinda Dunn as attorney-in-fact |
08/06/2010 |
|
By /s Melinda Dunn as attorney-in-fact |
08/06/2010 |
|
By /s/ Melinda Dunn as attorney-in-fact |
08/06/2010 |
|
By /s/ Melinda Dunn as attorney-in-fact |
08/06/2010 |
|
by /s/ Melinda Dunn as attorney-in-fact |
08/06/2010 |
|
By /s/ Melinda Dunn as attorney-in-fact |
08/06/2010 |
|
** Signature of Reporting Person |
Date |
| Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. |
| * 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). |
| Note: File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure. |
| Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. |
LIMITED POWER OF ATTORNEY
FOR
SECTION 16(a) FILINGS
Know all by these presents, that the undersigned hereby constitutes and
appoints Melinda Dunn the undersigned's true and lawful attorney in fact to:
(1) Execute for and on behalf of the undersigned, in the undersigned's capacity
as an officer, director and/or stockholder of any corporation or other person in
which an investment fund affiliated with Sequoia Capital Operations, LLC makes
an investment (each, a "Company"), Forms 3, 4, and 5 and amendments thereto in
accordance with Section 16(a) of the Securities Exchange Act of 1934 and the
rules thereunder;
(2) Do and perform any and all acts for and on behalf of the undersigned which
may be necessary or desirable to complete and execute any such Form 3, 4, or 5
or amendment thereto and timely file such form with the United States Securities
and Exchange Commission (the "SEC") and any stock exchange or similar authority;
and
(3) Take any other action of any type whatsoever which, in the opinion of such
attorney in fact, may be necessary or desirable in connection with the foregoing
authority, it being understood that the documents executed by such attorney in
fact on behalf of the undersigned pursuant to this Limited Power of Attorney
shall be in such form and shall contain such terms and conditions as such
attorney in fact may approve.
The undersigned hereby grants to such attorney in fact full power and authority
to do and perform any and every act and thing whatsoever required, necessary, or
proper to be done in the exercise of any of the rights and powers herein
granted, as fully to all intents and purposes as the undersigned might or could
do if personally present, with full power of substitution or revocation, hereby
ratifying and confirming all that such attorney in fact, or such attorney in
fact's substitute or substitutes, shall lawfully do or cause to be done by
virtue of this Limited Power of Attorney and the rights and powers herein
granted. The undersigned acknowledges that the foregoing attorney in fact, in
serving in such capacity at the request of the undersigned, is not assuming, nor
is any Company assuming, any of the undersigned's responsibilities to comply
with Section 16 of the Securities Exchange Act of 1934.
This Limited Power of Attorney shall remain in full force and effect until the
undersigned is no longer required to file Forms 3, 4, and 5 with respect to any
Company, unless earlier revoked by the undersigned in a signed writing delivered
to the foregoing attorney in fact. This Limited Power of Attorney may be filed
with the SEC as a confirming statement of the authority granted herein.
[Signature Page Follows]
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IN WITNESS WHEREOF, the undersigned has caused this Limited Power of Attorney to
be executed as of this 24th day of August, 2009.
/s/ ROELOF BOTHA
Roelof Botha
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IN WITNESS WHEREOF, the undersigned has caused this Limited Power of Attorney to
be executed as of this 24th day of August, 2009.
/s/ SCOTT CARTER
Scott Carter
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IN WITNESS WHEREOF, the undersigned has caused this Limited Power of Attorney to
be executed as of this 24th day of August, 2009.
/s/ JAMES GOETZ
James Goetz
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IN WITNESS WHEREOF, the undersigned has caused this Limited Power of Attorney to
be executed as of this 24th day of August, 2009.
/s/ MICHAEL GOGUEN
Michael Goguen
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IN WITNESS WHEREOF, the undersigned has caused this Limited Power of Attorney to
be executed as of this 21st day of August, 2009.
/s/ DOUGLAS LEONE
Douglas Leone
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IN WITNESS WHEREOF, the undersigned has caused this Limited Power of Attorney to
be executed as of this 2nd day of August, 2010.
/s/ MARK STEVENS
Mark Stevens
