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*
C/O TECHNOLOGY CROSSOVER VENTURES |
528 RAMONA STREET |
(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)
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Director |
X |
10% Owner |
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Officer (give title below) |
X |
Other (specify below) |
May be part of a 13(d) group |
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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)
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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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Class A Common Stock |
97 |
I |
TCV Member Fund, L.P.
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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)
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6. Nature of Indirect Beneficial Ownership (Instr.
5)
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Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
Class B Common Stock
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Class A Common Stock |
11,195 |
0 |
I |
TCV Member Fund, L.P.
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1. Name and Address of Reporting Person*
C/O TECHNOLOGY CROSSOVER VENTURES |
528 RAMONA STREET |
(Street)
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1. Name and Address of Reporting Person*
C/O TECHNOLOGY CROSSOVER VENTURES |
528 RAMONA STREET |
(Street)
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1. Name and Address of Reporting Person*
C/O TECHNOLOGY CROSSOVER VENTURES |
528 RAMONA STREET |
(Street)
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1. Name and Address of Reporting Person*
C/O TECHNOLOGY CROSSOVER VENTURES |
528 RAMONA STREET |
(Street)
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Explanation of Responses: |
Remarks: |
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Frederic D. Fenton Authorized signatory for TCV Mermber Fund, L.P. |
08/06/2010 |
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Frederic D. Fenton Authorized signatory for Christopher P. Marshall |
08/06/2010 |
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Frederic D. Fenton Authorized signatory for Timothy P. McAdam |
08/06/2010 |
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Frederic D. Fenton Authorized signatory for John C. Rosenberg |
08/06/2010 |
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** 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. |
CONFIRMING STATEMENT
This statement confirms that Jay C. Hoag, Richard H. Kimball, John L. Drew, Jon
Q. Reynolds, Jr., William J.G. Griffith IV, Robert W. Trudeau, Christopher P. Marshall,
Timothy P. McAdam, John C. Rosenberg, Technology Crossover Management VII, L.P., Technology Crossover
Management VII, LTD.,TCV VII, L.P., TCV VII (A), L.P.
and TCV Member Fund, L.P. ("Filers"), have authorized and designated Robert C. Bensky,
Carla S. Newell, Patrick D. Reilly and Frederic D. Fenton to execute and file on
the Filers' behalf all Forms 3, 4 and 5 (including any amendments thereto) that the Filers
may be required to file with the U.S. Securities and Exchange Commission as a result of
the Filers' ownership of or transactions in securities of Green Dot Corporation. The
authority of Robert C. Bensky, Carla S. Newell, Patrick D. Reilly and Frederic D. Fenton under
this statement shall continue until the Filers are no longer required to file Forms 3, 4 and 5
with regard to their ownership of or transactions in securities of Green Dot Corporation, unless revoked in
writing. The Filers acknowledge that Robert C. Bensky, Carla S. Newell, Patrick D. Reilly and Frederic D. Fenton
are not assuming any of the Filers' responsibilities to comply with Section 16 of the Securities
Exchange Act of 1934.
Date: August 6, 2010
s/ Jay C. Hoag
Jay C. Hoag
s/ Richard H. Kimball
Richard H. Kimball
s/ John L. Drew
John L. Drew
s/ Jon Q. Reynolds, Jr.
Jon Q. Reynolds, Jr.
s/ William J. G. Griffith IV
William J.G. Griffith IV
s/ Robert W. Trudeau
Robert W. Trudeau
s/ Christopher P. Marshall
Christopher P. Marshall
s/ Timothy P. McAdam
Timothy P. McAdam
s/ John C. Rosenberg
John C. Rosenberg
s/ Technology Crossover Management VII, L.P.
Technology Crossover Management VII, L.P.
s/ Technology Crossover Management VII, LTD.
Technology Crossover Management VII, LTD.
s/ TCV VII, L.P.
TCV VII, L.P.
s/ TCV VII (A), L.P.
TCV VII (A), L.P.
s/ TCV Member Fund, L.P.
TCV Member Fund, L.P.